Left atrial veno-arterial extracorporeal membrane oxygenation as a bridge to surgical or percutaneous closure of post-myocardial infarction ventriculoseptal defects: a case series.

Post-myocardial infarct (MI) ventricular septal defect (VSD) is a rare and severe complication of an acute MI with high mortality rate. The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge to surgical or percutaneous repair in cardiogenic shock secondary to post-MI-VSD has been published, but is limited to small case series primarily utilizing surgical ECMO, with the main drawback of potentially increasing afterload and left ventricle pressure, further worsening VSD shunting. Left-atrial VA-ECMO (LAVA-ECMO) can potentially absolve this concern given that it utilizes bi-atrial drainage through a trans-septal fenestrated cannula. Five patients were included in this series, all with VSD secondary to MI, and all managed with LAVA-ECMO as a bridge to repair. Average age was 62 ± 4.2 years, body mass index of 29.4 ± 4.5 kg/m2, and left ventricular ejection fraction of 46.6 ± 13.8%. Haemodynamics monitoring pre- and post-LAVA-ECMO demonstrated improvement in right atrial, right ventricular, pulmonary, left atrial, and left ventricular pressures (Figure 1). Average time to repair was 7.4 ± 3.9 days. All five patients survived to repair, with four undergoing surgical and one undergoing percutaneous closure. Four out of five patients were decannulated successfully. This case series reports the successful use of LAVA-ECMO as a bridge to MI-VSD repair in patients with cardiogenic shock. Left-atrial VA-ECMO serves as a convenient approach to managing patients with MI-VSD related cardiogenic shock as it is implanted percutaneously, and can be done at the time of shock diagnosis, during right heart catheterization by trained interventionists.