Transseptal balloon atrial septostomy for decompression of the left atrium during extracorporeal membrane oxygenation support as a “bridge to transplantation” in dilated cardiomyopathy

Introduction

We report the case of a 54-year-old woman with dilated cardiomyopathy who developed severe biventricular failure unresponsive to conventional therapy. She was placed on extracorporeal membrane oxygenation (ECMO) as a bridge to decision and required transseptal balloon atrial septostomy for decompression of the left atrium during mechanical circulatory support.

Case report

A 54-year-old woman with negative family history for heart diseases was transferred to our institution with the diagnosis of dilated cardiomyopathy resulting in advanced biventricular failure. She required 3 hospitalizations during the past 6 months due to heart failure exacerbation for intravenous diuretics and inotropic therapy fulfilling the criteria of Frequent Flyer – a modifier of the INTERMACS Patient Profiles designated for a patient requiring frequent emergency visits or hospitalizations for intravenous diuretics, ultrafiltration, or brief inotropic support. The need for a heart transplant was introduced and a formal workup began. The physical examination revealed significant cardiac enlargement and findings of congestive heart failure: peripheral edema, pulsatile nontender liver edge palpable 8 cm below the costal margin, ascites, grossly pulsatile and distended jugular veins and yellow pigmentation of sclerae. Results of laboratory tests were as follows: bilirubin 68 mmol/l, estimated glomerular filtration rate (eGFR) 44 ml/min/1.73 m2, NT-pro-BNP 8500 pg/ml, Hb 10.7 g/dl. Chest X-rays showed a grossly dilated cardiac shadow and pulmonary congestion. Echocardiography revealed a left ventricular diastolic diameter of 88 mm with diffuse reduction in wall motion and an ejection fraction of 10%. The right ventricle was also significantly enlarged (right ventricular outflow tract (RVOT) 52 mm) with hypokinesis (tricuspid annular plane systolic excursion (TAPSE) 13 mm). Severe mitral and tricuspid regurgitation was also present. Coronary arteriography showed normal vessels and the cardiac catheterization revealed elevated left-ventricular end-diastolic, left atrial and pulmonary artery wedge pressures. A degree of pulmonary arterial hypertension was also present (pulmonary artery pressure (PAP) 50/27/36 mm Hg, pulmonary artery resistance (PAR) 2.8 Wood units). Following a few days of clinical improvement she developed severe biventricular failure that was unresponsive to escalating doses of inotropes, vasodilators and diuretics. Considering the...


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