Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation In Valvular Cardiogenic Shock

Background: Treatment of valvular cardiogenic shock (VCS) is challenging as the options for mechanical cardiocirculatory support are limited. Left atrial veno-arterial extracorporeal membrane oxygenation (LAVA-ECMO) is a mechanical cardiocirculatory support strategy that provides cardiocirculatory support and simultaneous left ventricular unloading, compared to traditional VA-ECMO. Methods: This is a single-center retrospective analysis of patients with VCS who underwent LAVA-ECMO between 2018 and 2023. During LAVA-ECMO, the ECMO venous cannula is placed transeptally in the LA, therefore providing active biventricular unloading. Results: A total of 18 patients who had VCS and underwent LAVA-ECMO cannulation were included. Among patients with VCS, 10 were related to the aortic valve (55.6%), 7 to the mitral valve (38.9%), and 1 to the tricuspid valve (5.6%). Four patients (22.2%) had multivalvular disease. The median age was 65 years, most were men (66.7%) and most were in Society for Cardiovascular Angiography & Interventions cardiogenic shock stage D or E (89%). LAVA-ECMO was associated with substantial improvement in hemodynamics, including lower right atrial pressure (–8 mm Hg; 95% CI, 7.0-9.5; P = .004), mean pulmonary artery systolic pressure (–18.5 mm Hg; 95% CI, 14.3-21.7; P = .026), pulmonary capillary wedge pressure (–14.5 mm Hg; 95% CI, 12.8-12.3; P = .003), and left ventricular end-diastolic pressure (–20.0 mm Hg; 95% CI, 16.5-21.0; P < .001). These effects were consistent across VCS types. There were no complications from transeptal cannulation. Survival to a transcatheter or surgical procedure was 69.1%, and survival to hospital discharge was 44.4%. Conclusions: LAVA-ECMO appears to be feasible, safe, and associated with improved hemodynamics in patients with VCS. Further research is needed to evaluate whether LAVA-ECMO as a bridge treatment strategy to intervention is beneficial in VCS.