Left atrial decompression during veno-arterial extracorporeal membrane oxygenation using a single multi-stage drainage cannula with a transseptal approach: Clinical significance and medical management of LAVA ECMO

Extracorporeal Membrane Oxygenation (ECMO) is a life-support treatment used in critically ill patients that temporarily acts as the heart and lungs. It is used in numerous clinical scenarios where the patient’s heart and/or lungs are too sick to work on their own. With ECMO, a patient’s blood is removed from the body and pumped through an artificial lung, where oxygen is added and carbon dioxide is removed. There are two types of ECMO support: VV ECMO and VA ECMO. VV ECMO is used when a patient’s lungs need additional support, and VA ECMO is used when a patient’s heart and lungs need additional support. Although ECMO therapy can be life-saving, it is a supportive therapy, not a disease-modifying treatment. There are numerous techniques and strategies used to implement ECMO, all in which come with their own risks, complications, and possible emergencies. Cannulation strategy is determined by a multitude of factors, such as materials available, patient presentation, concurrent venous/arterial access, specific patient anatomy, clinical diagnosis, provider training, etc. One major complication specific to VA ECMO is left ventricular overload, which can create a lethal cascade of issues for a patient receiving this mode of support. This manuscript will discuss the products and materials needed, cannulation techniques, configurations, and clinical significance of left atrial veno-arterial extracorporeal membrane oxygenation (LAVA ECMO). We will focus on clinical scenarios that allow for LAVA ECMO and unique considerations for this complex cannulation strategy. Additionally, we will address the use of LAVA ECMO in patients where traditional left atrial venting and decompression techniques are contraindicated. Finally, current data pertaining to patient outcomes related to the use of LAVA ECMO will be discussed in length, giving a synopsis of the benefits of using a single multi-stage drainage cannula with a transseptal approach for left atrial decompression in VA ECMO