The mechanical life support with extracorporeal membrane oxygenation (ECMO) is a valuable option for the treatment of refractory cardiogenic shock and an elegant solution as a bridge to recovery and/or decision making. It allows short-term support and restoration of adequate hemodynamic conditions with limitation of myocardial work and safely promotes myocardial recovery. But, sometimes, it will not be sufficient to offload the left ventricle especially in patients with severe ventricular dysfunction. The percutaneous blade and balloon atrioseptostomy could assume the left ventricular discharge. We present a case of a young man who presented for myocardial infarction with refractory cardiac arrest in which ECMO was insufficient to discharge the left ventricle and the blade and balloon atrioseptostomy was helpful to bail out.

A 20-year-old man, tobacco and cannabis smoker, with no cardiovascular past medical history, was transferred to our hospital for a refractory sudden cardiac arrest. Cardiopulmonary resuscitation was efficacious; the first electrocardiogram showed an anterior ST-segment elevation, and the cardiac ultrasound highlighted a severe myocardial dysfunction (left ventricular ejection fraction estimated at 10%) with an apical thrombus. Facing the recurrence of cardiac arrests and the hemodynamic instability despite the full inotropic support, he was immediately assisted by a venoarterial ECMO via the left femoral access. The coronary angiography via right transfemoral access demonstrated a huge thrombus of the distal left main coronary artery that occluded the ostium of the left anterior descending artery (LAD) with embolization to the distal part of the circumflex artery. The right coronary artery was normal and supplied by retrograde course the occluded LAD. The mean invasive central venous pressure (iCVP) recorded by right cardiac catheter was very high (45 mmHg). We decided to perform a blade and balloon atrioseptostomy to manage the severe and refractory acute lung edema. The modified Seldinger technique consists of placing an 8-Fr sheath in the right femoral vein and then switching to an 8-Fr Mullins sheath that we advanced into the right atrium. After transeptal puncture under fluoroscopy with a modified Brockenbrough needle, we advanced a 0.035’’ spring guide-wire into the right upper pulmonary vein. The Mullins sheath was then withdrawn, and a 10-mm Marshal balloon was advanced at the level of its midportion into the septum and was inflated with dilute contrast, creating an atrial septal defect with left-to-right shunting. The balloon was inflated and then pulled back from the left atrium to the right atrium, creating an atrial septal defect (ASD). The left ventricular discharge assumed by the ASD was immediately efficacious on the pulmonary edema, and the mean iCVP declined significantly (24 mmHg), which also reflected a decrease of the left atrium pressure. Indeed, the adequacy of atrioseptostomy was assessed by a better ECMO output. We decided not to treat the left main thrombus because of the disseminated coronary emboli. Later, the patient was transferred to the intensive care unit and was treated with therapeutic ranges of anticoagulation. He developed multiple organ failure that regressed progressively. The neurological status was favorable; the cardiac function did not show any recovery signs, which led to heart transplantation at day 10. The first days after heart transplantation were marked by a positive evolution, a fast weaning from vasoactive drugs and a preserved function of the graft. Unfortunately, the subsequent evolution was marked by an uncontrolled septic shock of unknown entry point probably favored by immunosuppressive therapy, and the patient died 7 days after transplantation.

Post-myocardial infarction cardiogenic shock still carries a very poor prognosis despite the rapid recourse to effective methods of myocardial revascularization . Extracorporeal life support leads to rapid restoration of hemodynamic conditions in patients with hemodynamic collapse that is due to cardiac arrest . It aims to assume a temporary circulatory support using venovenous or venoarterial pumping via an artificial lung in order to maintain organ perfusion in patients with cardiogenic shock refractory to optimal medical therapy . It has been shown to be life saving . After stabilization of the patient’s condition, there are several alternatives: ECMO weaning off and explantation in case of recovery (bridge-to-recovery), transplantation if there is no contraindication and no possible recovery (bridge-to-transplant) and finally implantation of a long-term assist device if there is no right ventricular dysfunction or organ failure (bridge-to-bridge) . However, ECMO may be insufficient to offload the left ventricle in patients with severe ventricular dysfunction, which leads to left ventricular dilation, high end-diastolic pressure, increased wall stress, subendocardial ischemia and consequently worsening pulmonary congestion and edema . Draining the left heart through a catheter into the left atrium can be achieved surgically via a minithoracotomy or percutaneously with catheter-based assist devices such as the Impella microaxial blood pump, a catheter-based left ventricular assist device inserted percutaneously or surgically . Their efficacy could be counterbalanced by the risk of device displacement, valvular and endovascular trauma (dissection, distal embolization), bleeding and infectious complications . An alternative technique is to perform a percutaneous blade and balloon atrioseptostomy, which was mainly used for congenital heart disease with pulmonary hypertension . The data concerning the adult population are scarce . The main advantage of blade and balloon atrioseptostomy is that left ventricular discharge can be achieved quickly in critically ill patients by a percutaneous approach that appeared less invasive without the risk of arterial or aortic valve damage. However, the technique requires transeptal catheter-based experience. The potential complications of this technique include needle perforation (left atrium wall, pulmonary vein), pericardial effusion or tamponade, hypotension and ventricular fibrillation.

In our case, the cannabis in association with tobacco smoke was the only risk factor for thrombus formation in the left main coronary artery in this young patient with smooth normal coronary artery. The consequent refractory cardiogenic shock led to the decision of circulatory assistance with an ECMO. The latter was insufficient to bail out, and a left ventricular discharge seemed mandatory. For this purpose, we performed a percutaneous blade and balloon atrioseptostomy that was immediately efficacious on the pulmonary edema, allowing a bridge to heart transplantation.

In conclusion, there is a current trend to use short-term support with ECMO in refractory cardiogenic shock especially for left heart. But in some cases, this technique seemed to be insufficient, and blade and balloon atrioseptostomy that requires transeptal catheter-based experience could be an advisable technique to supplement assistance as a bridge to partial recovery or to heart transplantation.