The authors utilized the NCDR IMPACT registry to assess the procedural safety and outcomes of percutaneous atrial septostomy (PAS) in pediatric patients supported with ventoarterial ECMO (VA-ECMO). A total of 223 patients from 55 sites were included. The primary finding of this work is that there was no procedural mortality but significant procedural morbidity (arrhythmia, tamponade, unplanned surgery, blood transfusion, vascular injury, etc.). The authors propose some risk factors for early post-procedural mortality (black race, chronic lung disease, and procedural urgency), but further investigation of these is warranted. Overall, there is little data regarding the timing or indications for PAS or the impact of PAS on ECMO outcomes, reflecting the IMPACT database's limitations. There is also no distinction made between balloon atrial septostomy vs. stent placement and no mention made of LA vent placement. Pediatric interventional cardiologists should be aware that PAS can be performed safely and keep it in their armamentarium for patients on VA-ECMO with signs of LA hypertension or poor ventricular recovery. However, uncertainty still exists regarding the exact indications, timing, and techniques for performing PAS.

All editors: Konstantin Averin, MD, MS

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