CHEST Guidelines-The-Atrial-Flow-Regulator

The-Atrial-Flow-Regulator_chest

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The document discusses the feasibility and efficacy of using the Atrial Flow Regulator (AFR) device for left ventricular unloading in patients undergoing venoarterial extracorporeal membrane oxygenation (VA ECMO). Patients on VA ECMO often face challenges like severe pulmonary edema due to increased left ventricular afterload. There is no consensus on managing this issue, but devices like Impella, balloon atrial septostomy, and intraaortic balloon counterpulsation have been used. However, this case study considers the AFR device as a potential solution.<br /><br />A case study of a 58-year-old patient with severe pulmonary edema while on VA ECMO is presented. The patient, who had refractory cardiogenic shock, underwent emergency VA ECMO due to rapid deterioration marked by electromechanical dissociation. Despite initial improvements, the patient developed severe pulmonary edema. A multidisciplinary team decided to use an AFR device instead of conventional methods. This device, placed via transseptal puncture through the femoral vein, allowed for controlled left-to-right shunt, reducing the left atrial pressure and pulmonary congestion. The patient's condition improved, facilitating extubation 12 hours post-implementation, underscoring the procedure's efficacy.<br /><br />The AFR device is shown to control long-term left-to-right shunting effectively with minimal complications compared to conventional atrial septostomy. Benefits of AFR over balloon septostomy need further exploration. The document highlights risks like prosthesis embolization and emphasizes the need for antiplatelet therapy. While promising, AFR application requires more study to ascertain its benefits fully. The authors declare no financial disclosures, and thank Raphaëlle-Ashley Guerbaai for manuscript editing, providing references from previous studies on similar methods.

Keywords

Atrial Flow Regulator

left ventricular unloading

venoarterial extracorporeal membrane oxygenation

VA ECMO

pulmonary edema

cardiogenic shock

transseptal puncture

left-to-right shunt

antiplatelet therapy

prosthesis embolization