Left ventricular decompression in paediatric veno‐arterial extracorporeal life support: Reviewing the evidence
Abstract Veno‐arterial extracorporeal life support (VA ECLS) is crucial for neonatal and paediatric patients with severe circulatory collapse but may cause left ventricular (LV) overload, affecting myocardial recovery and causing complications. Evidence on optimal LV decompression strategies in paed...
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Wiley
2025-08-01
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| Series: | ESC Heart Failure |
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| Online Access: | https://doi.org/10.1002/ehf2.15325 |
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| author | Giacomo Veronese Paolo Meani Domenico Sirico Giovanni Di Salvo Enrico Ammirati Alessandro Varrica Umberto Di Dedda Paolo Bianchi Giuseppe Isgrò Alessandro Giamberti Tommaso Aloisio Marc Dickstein Ezio Bonanomi Bahaaldin Alsoufi Ravi R. Thiagarajan Peta M.A. Alexander D. Michael McMullan Ryan P. Barbaro Graeme MacLaren Marco Ranucci Navin K. Kapur Roberto Lorusso |
| author_facet | Giacomo Veronese Paolo Meani Domenico Sirico Giovanni Di Salvo Enrico Ammirati Alessandro Varrica Umberto Di Dedda Paolo Bianchi Giuseppe Isgrò Alessandro Giamberti Tommaso Aloisio Marc Dickstein Ezio Bonanomi Bahaaldin Alsoufi Ravi R. Thiagarajan Peta M.A. Alexander D. Michael McMullan Ryan P. Barbaro Graeme MacLaren Marco Ranucci Navin K. Kapur Roberto Lorusso |
| author_sort | Giacomo Veronese |
| collection | DOAJ |
| description | Abstract Veno‐arterial extracorporeal life support (VA ECLS) is crucial for neonatal and paediatric patients with severe circulatory collapse but may cause left ventricular (LV) overload, affecting myocardial recovery and causing complications. Evidence on optimal LV decompression strategies in paediatric patients remains limited. We conducted a systematic review following PRISMA guidelines, including articles published between 1993 and 2024 focused on VA ECLS and LV decompression in patients under 18 years of age. The review included 11 retrospective cohorts and registry‐based studies (2012–2024), totalling 1222 paediatric patients undergoing decompression. Patient demographics, initial diagnoses and VA ECLS settings were heterogeneous. The prevalence of LV decompression ranged from 46.6% in post‐cardiotomy to 10.5% in non‐post‐cardiotomy peripheral VA ECLS cases. Most patients (57.1%) were supported with peripheral VA ECLS, and the majority (57.4%) underwent percutaneous decompression, whereas surgical approaches predominated in post‐cardiotomy central VA ECLS. Balloon atrial septostomy (BAS) was the most frequent technique (50%), followed by surgically placed left atrial cannula (37.4%). Thirteen case series (70 patients) and 28 case reports (28 patients) were also reviewed. Substantial variability in LV decompression strategies exists based on age and clinical scenario. PAS‐based techniques were more common in younger patients on peripheral VA ECLS while older children often underwent different strategies. Surgical approaches were preferred in central VA ECLS, particularly in the post‐cardiotomy setting. Procedural safety varied by technique. While PAS‐based strategies such as BAS generally showed low complication rates, adverse events like arrhythmia, bleeding and cardiac perforation were reported in 7%–9% of cases. Surgical LA cannulation was associated with higher bleeding risk. Impella use was linked to haemolysis (50%) and major bleeding (20%). Comparative data highlight that each technique carries distinct procedural risks and complication profiles. In conclusion, LV decompression during paediatric VA ECLS remains technically challenging and variably adopted. Its benefit appears more consistent in the post‐cardiotomy setting, where improved survival and reduced adverse outcomes were observed. Given the lack of standardization, further prospective studies and collaborative registries are essential to guide strategy selection, timing and risk–benefit balance, particularly in such a vulnerable population. |
| format | Article |
| id | doaj-art-4e75530137e146b19e54dc1fd90200f7 |
| institution | DOAJ |
| issn | 2055-5822 |
| language | English |
| publishDate | 2025-08-01 |
| publisher | Wiley |
| record_format | Article |
| series | ESC Heart Failure |
| spelling | doaj-art-4e75530137e146b19e54dc1fd90200f72025-08-20T03:15:33ZengWileyESC Heart Failure2055-58222025-08-011242711272510.1002/ehf2.15325Left ventricular decompression in paediatric veno‐arterial extracorporeal life support: Reviewing the evidenceGiacomo Veronese0Paolo Meani1Domenico Sirico2Giovanni Di Salvo3Enrico Ammirati4Alessandro Varrica5Umberto Di Dedda6Paolo Bianchi7Giuseppe Isgrò8Alessandro Giamberti9Tommaso Aloisio10Marc Dickstein11Ezio Bonanomi12Bahaaldin Alsoufi13Ravi R. Thiagarajan14Peta M.A. Alexander15D. Michael McMullan16Ryan P. Barbaro17Graeme MacLaren18Marco Ranucci19Navin K. Kapur20Roberto Lorusso21Pediatric Intensive Care Unit ASST Papa Giovanni XXIII Bergamo ItalyDepartment of Cardiothoracic Surgery, Heart and Vascular Centre Maastricht University Medical Centre Maastricht The NetherlandsPediatric Cardiology Unit, Department of Women's and Children's Health University of Padua Padua ItalyPediatric Cardiology Unit, Department of Women's and Children's Health University of Padua Padua ItalyDe Gasperis Cardio Center Niguarda Hospital Milan ItalyDepartment of Congenital Cardiac Surgery IRCCS Policlinico San Donato Milan ItalyDepartment of Cardiovascular Anesthesia and Intensive Care IRCCS Policlinico San Donato, San Donato Milanese Milan ItalyDivision of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer Imperial College London London UKDepartment of Cardiovascular Anesthesia and Intensive Care IRCCS Policlinico San Donato, San Donato Milanese Milan ItalyDepartment of Congenital Cardiac Surgery IRCCS Policlinico San Donato Milan ItalyDepartment of Cardiovascular Anesthesia and Intensive Care IRCCS Policlinico San Donato, San Donato Milanese Milan ItalyDivision of Cardiothoracic Anesthesia Columbia University Medical Center New York New York USAPediatric Intensive Care Unit ASST Papa Giovanni XXIII Bergamo ItalyDepartment of Cardiovascular and Thoracic Surgery University of Louisville Louisville Kentucky USADepartment of Cardiology, Boston Children's Hospital and Department of Pediatrics Harvard Medical School Boston Massachusetts USADepartment of Cardiology, Boston Children's Hospital and Department of Pediatrics Harvard Medical School Boston Massachusetts USACardiac Surgery Unit Seattle Children Hospital Seattle Washington USADivision of Critical Care C.S. Mott Children's Hospital, University of Michigan Ann Arbor Michigan USACardiothoracic Intensive Care Unit National University Hospital SingaporeDepartment of Cardiovascular Anesthesia and Intensive Care IRCCS Policlinico San Donato, San Donato Milanese Milan ItalyThe Cardiovascular Center Tufts Medical Center Boston Massachusetts USADepartment of Cardiothoracic Surgery, Heart and Vascular Centre Maastricht University Medical Centre Maastricht The NetherlandsAbstract Veno‐arterial extracorporeal life support (VA ECLS) is crucial for neonatal and paediatric patients with severe circulatory collapse but may cause left ventricular (LV) overload, affecting myocardial recovery and causing complications. Evidence on optimal LV decompression strategies in paediatric patients remains limited. We conducted a systematic review following PRISMA guidelines, including articles published between 1993 and 2024 focused on VA ECLS and LV decompression in patients under 18 years of age. The review included 11 retrospective cohorts and registry‐based studies (2012–2024), totalling 1222 paediatric patients undergoing decompression. Patient demographics, initial diagnoses and VA ECLS settings were heterogeneous. The prevalence of LV decompression ranged from 46.6% in post‐cardiotomy to 10.5% in non‐post‐cardiotomy peripheral VA ECLS cases. Most patients (57.1%) were supported with peripheral VA ECLS, and the majority (57.4%) underwent percutaneous decompression, whereas surgical approaches predominated in post‐cardiotomy central VA ECLS. Balloon atrial septostomy (BAS) was the most frequent technique (50%), followed by surgically placed left atrial cannula (37.4%). Thirteen case series (70 patients) and 28 case reports (28 patients) were also reviewed. Substantial variability in LV decompression strategies exists based on age and clinical scenario. PAS‐based techniques were more common in younger patients on peripheral VA ECLS while older children often underwent different strategies. Surgical approaches were preferred in central VA ECLS, particularly in the post‐cardiotomy setting. Procedural safety varied by technique. While PAS‐based strategies such as BAS generally showed low complication rates, adverse events like arrhythmia, bleeding and cardiac perforation were reported in 7%–9% of cases. Surgical LA cannulation was associated with higher bleeding risk. Impella use was linked to haemolysis (50%) and major bleeding (20%). Comparative data highlight that each technique carries distinct procedural risks and complication profiles. In conclusion, LV decompression during paediatric VA ECLS remains technically challenging and variably adopted. Its benefit appears more consistent in the post‐cardiotomy setting, where improved survival and reduced adverse outcomes were observed. Given the lack of standardization, further prospective studies and collaborative registries are essential to guide strategy selection, timing and risk–benefit balance, particularly in such a vulnerable population.https://doi.org/10.1002/ehf2.15325left ventricular decompressionpaediatricveno‐arterial extracorporeal life supportventingunloading |
| spellingShingle | Giacomo Veronese Paolo Meani Domenico Sirico Giovanni Di Salvo Enrico Ammirati Alessandro Varrica Umberto Di Dedda Paolo Bianchi Giuseppe Isgrò Alessandro Giamberti Tommaso Aloisio Marc Dickstein Ezio Bonanomi Bahaaldin Alsoufi Ravi R. Thiagarajan Peta M.A. Alexander D. Michael McMullan Ryan P. Barbaro Graeme MacLaren Marco Ranucci Navin K. Kapur Roberto Lorusso Left ventricular decompression in paediatric veno‐arterial extracorporeal life support: Reviewing the evidence ESC Heart Failure left ventricular decompression paediatric veno‐arterial extracorporeal life support venting unloading |
| title | Left ventricular decompression in paediatric veno‐arterial extracorporeal life support: Reviewing the evidence |
| title_full | Left ventricular decompression in paediatric veno‐arterial extracorporeal life support: Reviewing the evidence |
| title_fullStr | Left ventricular decompression in paediatric veno‐arterial extracorporeal life support: Reviewing the evidence |
| title_full_unstemmed | Left ventricular decompression in paediatric veno‐arterial extracorporeal life support: Reviewing the evidence |
| title_short | Left ventricular decompression in paediatric veno‐arterial extracorporeal life support: Reviewing the evidence |
| title_sort | left ventricular decompression in paediatric veno arterial extracorporeal life support reviewing the evidence |
| topic | left ventricular decompression paediatric veno‐arterial extracorporeal life support venting unloading |
| url | https://doi.org/10.1002/ehf2.15325 |
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