CASE REPORT
Arterial and venous femoral sheaths were placed, general anesthesia was induced, the patient intubated, and a transesophageal echocardiography (TEE) probe placed (Movie 1) . TEE revealed biventricular dysfunction with a severely dilated left ventricle (LV) (12.1 cm at end-diastole) (Figure 1) , a LV ejection fraction of <10%, spontaneous echo contrast in all chambers but no thrombus appreciated, severe mitral and tricuspid regurgitation, a mitral annuloplasty ring, mild central aortic insufficiency (AI), and a dilated pulmonary valve annulus (3.8cm) with mild insufficiency. A 6F, 24cm sheath was placed in the superficial femoral artery for antegrade perfusion of the extremity. Under direct, continuous TEE guidance a BRK needle (St. Jude Medical, Minnesota, USA) was employed for transseptal puncture (Movie 2 ) and a ProTrack Pigtail Wire (Baylis Medical, Texas, USA) was inserted. Atrial septostomy was performed with a 6mm x 40mm peripheral balloon (Movie 3 ) and the venous tract was dilated to accommodate the venous cannula. A 23F Medtronic Bio-Medicus NextGen Multistage Venous Cannula (Medtronic, Minnesota, USA) was placed and guided in real-time across the IAS using a combination of live 2D and 3D TEE imaging (Movies 4 and 6 ). Positioning of the venous cannula was achieved using 3D imaging to optimize distance across the IAS, ensure location of distal orifice and side ports in relation to the IAS, and avoid damage or interaction with intracardiac structures (Figures 2-4) (Movies 6 and 7 ). Specifically, 3D imaging was integral to visualizing the relationship of the distal tip of the cannula and side ports to the aorta, the IAS, and the mitral valve. An orientation of the image to project a view from the perspective of the base of the heart was particularly useful (Figure 4, Movie 7 ). Measurements were obtained “online” at the time of positioning utilizing 3D multiplanar reconstruction (3DQ QLAB, Philips Medical Systems, Best, Netherlands) with offline demonstration of workflow used to align three planes for cannula measurement presented in Figure 5 (4D CARDIOVIEW (v 2.30), TOMTEC Corporation USA, Illinois, USA).
LAVA-ECMO was initiated and flows adjusted to balance chamber decompression and to allow for continued opening of the aortic valve with each cardiac cycle. Color Doppler inflow was noted through the distal tip and side ports of the cannula within the LA (Figure 6 ). The patient was extubated uneventfully and returned to the cardiothoracic intensive care unit. The patient demonstrated symptomatic improvement and was able to ambulate in the hallways of the unit with assistance. Two days after initiation of VA-ECMO the patient underwent orthotopic heart transplantation. He is currently doing well.