INTRODUCTION
A 53 year-old male with chronic combined heart failure (HF) due to dilated ischemic cardiomyopathy presented in cardiogenic shock to the hybrid catheterization lab for institution of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge to cardiac transplantation. To provide adequate drainage and decompression of both right and left atria the decision was made to place a single venous cannula across the interatrial septum (IAS) with the goal of positioning the distal orifice and side ports within the left atrium (LA) and the proximal set of side ports within the right atrium (RA) or inferior vena cava (IVC) for left atrial veno-arterial (LAVA)-ECMO1,2. Three-dimensional (3D) transesophageal echocardiography (TEE) was employed to guide cannula placement and positioning.