Introduction: Conventional veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is contraindicated in severe aortic insufficiency (AI) due to exacerbated left ventricular (LV) distension. Similarly, intra-aortic balloon pumps (IABP) and Impella devices are limited in this setting. Left Atrial Veno-Arterial (LAVA) ECMO offers a promising alternative by providing direct LV decompression.
Description: We present a case of a 34-year-old male with bioprosthetic aortic valve dehiscence leading to severe AI and cardiogenic shock. The patient was successfully supported with LAVA-ECMO, involving transseptal cannulation for left atrial drainage, enabling effective LV unloading and systemic perfusion. He underwent successful surgical repair and was eventually discharged to a long-term care facility. LAVA-ECMO provided immediate hemodynamic stabilization, preventing LV distension and pulmonary edema. The patient tolerated the procedure well, allowing for bridge to definitive surgical intervention. Post-operative course was complicated by intracerebral hemorrhage and respiratory failure, but he ultimately recovered and was decannulated from ECMO.
Discussion: ECMO, a life-saving modality, has inherent limitations. Peripheral VA-ECMO and IABP are contraindicated in severe aortic insufficiency (AI) due to exacerbated left ventricular distension and pulmonary edema. Impella is a relative contraindication in severe AI, as transvalvular placement can worsen regurgitation. Central VA-ECMO offers an alternative with antegrade flow but requires invasive surgery, limiting its feasibility in critically ill patients. LAVA ECMO emerges as a promising novel strategy for severe AI. It directly unloads the left ventricle by draining blood from the left atrium, bypassing the regurgitant aortic valve and preventing afterload increase. LAVA ECMO is less invasive than central VA-ECMO, often established percutaneously, suggesting reduced complications and faster recovery. Case series by Villablanca et al. (2022), Phillip et al. (2023), and Giustino et al. (2025) demonstrate its efficacy in improving hemodynamics and bridging to definitive therapy. Optimal outcomes depend on early initiation, meticulous anticoagulation, infection prevention, and aggressive rehabilitation.
