Left ventricular unloading via transseptal percutaneous cannulation in patients with Veno arterial extracorporeal membrane oxygenation: report of two cases.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is widely used for short-term mechanical circulatory support in cardiogenic shock and refractory cardiac arrest. However, increased left ventricular (LV) afterload during VA-ECMO may lead to LV distension, a complication associated with myocardial injury, pulmonary congestion, and thromboembolic risk. Various strategies for LV unloading have been described, but experience with percutaneous transseptal LV cannulation in adults remains limited. We report two adult patients with cardiogenic shock supported with peripheral VA-ECMO who developed severe LV distension refractory to medical therapy and intra-aortic balloon pump support. In both cases, LV unloading was achieved via percutaneous transseptal cannulation of the left ventricle, with the cannula connected to the ECMO venous circuit. The procedures were performed successfully under fluoroscopic and echocardiographic guidance, resulting in effective LV decompression. One patient was successfully bridged to heart transplantation after six days of support, while the second patient, despite adequate LV unloading, developed multiple ECMO-related complications and died after prolonged support. These cases demonstrate that percutaneous transseptal LV cannulation is feasible, and appears to be safe and effective for LV unloading in adult patients receiving peripheral VA-ECMO. This approach provides an alternative to other unloading strategies, particularly in settings where devices such as Impella® are unavailable. Our experience supports its potential role in managing LV distension in selected patients. However, further studies are needed to better define patient selection, procedural safety, and clinical outcomes associated with this technique.