Surgical minimal invasive left atrial decompression during venoarterial extracorporeal membrane oxygenation for pediatric acute fulminant myocarditis

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has been considered as the first-line treatment for acute fulminant myocarditis (AFM) when traditional treatment is ineffective. Peripheral vascular VA ECMO can partially reduce right ventricular preload, but it can increase left ventricular (LV) afterload.1 The increased afterload may cause difficulty in LV blood ejection in patients with severely impaired LV function. In addition, it may result in secondary LV dilatation, pulmonary edema, intraventricular thrombosis, and even increased LV diastolic pressure, leading to myocardial ischemia and irreversible cardiac function, affecting the prognosis of the disease.2 Timely LV decompression can help to improve the prognosis.3 Here, we report a successful case of applying a surgical minimal invasive left atrial decompression method, and we discuss the appropriate timing and method of LV decompression during ECMO supporting in pediatric AFM. A 2-year-old girl with AFM was implanted with VA ECMO because of cardiac shock refractory to conventional therapy. The pulse pressure difference was less than 10 mm Hg, the LV ejection fraction (LVEF) was 20% and the LV dilated diameter (LVDD) was 36 mm while ECMO initiated. In addition, fluid intake was limited to 60% of normal physiological requirements. Epinephrine was maintained at 0.3 µg/kg/min. ECMO blood flow was titrated to mean arterial blood pressure (MABP) >50 mm Hg and venous oxygen saturation >65% to reduce LV afterload as low as possible. Urine output and serum lactate were monitored. On the 24th hour of ECMO running, the MABP increased to 80 mm Hg and pulse pressure difference declined to less than 5 mm Hg. Echocardiography showed that the LVEF decreased to 10%, LVDD increased …