J Cardiovasc Interv.  2025 Jul;4(3):184-200. 10.54912/jci.2025.0002.

Left Heart Venting or Unloading Strategies for VA-ECMO Patients: Indications, Timing, and Techniques: A Narrative Review

• Jo Y
• Seong J
• Cho HJ
• Kim DW
• Lim Y
• Cho YH
• Song S
• Kim MC
• Jeong I

• KMID: 2570250
• DOI: http://doi.org/10.54912/jci.2025.0002

Abstract

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a critical intervention for patients with cardiac or respiratory failure, as it provides essential circulatory support and oxygenation. However, its implementation often leads to left ventricular (LV) distension due to increased afterload, which can hinder cardiac recovery and precipitate complications such as pulmonary congestion, refractory ventricular arrhythmia, and blood stagnation in the LV cavity. To mitigate these challenges, venting or unloading strategies have been proposed. This narrative review examines the indications, timing, and techniques of left heart venting or unloading in VA-ECMO patients. Recent studies underscore the pathophysiological rationale for unloading by emphasizing its role in reducing myocardial oxygen consumption, alleviating LV strain, and improving overall cardiac function. Current evidence, including randomized controlled trials and retrospective analyses, highlights the importance of early, targeted intervention in patients with severe LV dysfunction or signs of pulmonary congestion. Various techniques, including percutaneous and surgical approaches, are evaluated for their efficacy and safety. Although recent research stresses the need for timely intervention to prevent adverse outcomes, further studies are required to refine indications, optimize strategies, and standardize clinical practices. This review synthesizes existing data to guide future research and enhance patient outcomes in the context of VA-ECMO.

Keyword

Extracorporeal membrane oxygenation; Cardiogenic shock; Heart-assist devices; Decompression; Time factors