Over the past decade, extracorporeal life support (ECLS) has gained increasing utilization in the management of refractory cardiogenic shock (CS) with a class IIaC recommendation according to the latest European and US guidelines.¹ However, recent randomized controlled trials (RCTs) and meta-analyses can be considered inconclusive in demonstrating the benefit of ECLS compared with optimal medical treatment in patients with acute myocardial infarction complicated by CS.

Various factors may explain these neutral results but the inherent haemodynamic effect of the ECLS itself probably plays a major role. Due to its aortic retrograde flow principle, peripheral ECLS can lead to left ventricular (LV) overload and distension, increased myocardial workload and pulmonary oedema, compromising cardiac recovery, and diming the patient’s prognosis. To optimize the chances of ECLS outcomes with good heart recovery, several left heart decompression (LHD) strategies have been proposed. However, all strategies are invasive, entail risks of bleeding, haemolysis and thromboembolic complications, and the risk–benefit ratio of their use remains unclear.² Despite limited available data, recent guidelines suggest early initiation of LHD after ECLS initiation (class IIaC) without further defining the preferred unloading technique or its implementation timing after ECLS.¹

Left heart decompression techniques aim to unload the left ventricle by increasing the forward flow, achieved either indirectly with the intra-aortic balloon pump (IABP) or directly through microaxial flow pumps, or through left atrial (LA) drainage (atrioseptostomy) or active transapical venting (Figure 1). Active LA venting implies the implementation of an atrioseptostomy in combination with a 21–23 Fr cannula inserted through the interatrial septum and connected in ‘Y’ to the venous ECLS circuit which remains in place for several days. Its achievement justifies multidisciplinary skills and expertise assuring safe septal defect realization and correct cannula positioning, but also close circuit monitoring during the ECLS run.