Left ventricular (LV) overload is a recognized complication of venoarterial extracorporeal membrane oxygenation (VA-ECMO), but pediatric decompression remains technically challenging and poorly standardized.¹ The atrial flow regulator (AFR) (Occlutech) is a transcatheter device designed to create a controlled interatrial shunt; however, experience with AFR implantation in infants and toddlers is limited.²

In a 19-month-old child (12 kg) with refractory cardiogenic shock due to hypokinetic dilated cardiomyopathy, cervical VA-ECMO restored systemic perfusion but was followed by progressive LV overload, manifested by pulmonary congestion on chest radiography (Figure 1). Echocardiography showed severe LV dysfunction, spontaneous echo contrast in the left-sided chambers, and a persistently closed aortic valve, supporting the need for urgent left-heart decompression. A fully percutaneous transseptal strategy was chosen. Under transesophageal echocardiographic guidance, an 8-Fr long sheath was placed in the superior vena cava and a BRK needle positioned against the thickened interatrial septum, showing clear septal tenting. Because of the patient’s small size, a SafeSept 0.014-inch guidewire was advanced through the needle, crossed the septum smoothly, and was parked in a left pulmonary vein, allowing controlled advancement of the needle, dilator, and sheath into the left atrium. After predilation with an 8 × 20-mm balloon, an 8/5-mm AFR was successfully implanted. Postprocedural imaging confirmed stable device position and an unrestrictive left-to-right shunt (Video 1). Left atrial pressure decreased from 16 to 9 mm Hg, with immediate improvement in pulmonary venous congestion, resolution of the echocardiographic signs of LV overload, restoration of arterial pulsatility, and no procedural complications. This image sequence highlights AFR implantation as a minimally invasive option for LV decompression during pediatric VA-ECMO and illustrates how adjunctive SafeSept wire crossing may facilitate safer transseptal access in infants and toddlers.