Prolonged ECMO support in a pediatric patient with complex cardiac conditions during wartime in Kyiv, Ukraine

In the conflict-affected setting of Kyiv, Ukraine, managing complex medical interventions presents significant challenges, especially for critically ill pediatric patients. This case report describes the prolonged use of extracorporeal membrane oxygenation (ECMO) in a 12-year-old girl with severe congenital heart disease, including critical aortic stenosis and myocarditis. In the absence of a transplant system and with limited resources, alternative solutions were explored to balance the high risk of complications and maintain ECMO support over an extended period.

The patient received ECMO support for a total of 259 days, utilizing both VV-ECMO and VA-ECMO configurations. Due to wartime supply issues, polypropylene fiber oxygenators, specifically the Quadrox-i and Terumo Fx15 models, were used despite not being indicated for long-term use. Eleven oxygenators were employed, with a total of ten replacements due to thrombosis and technical malfunctions. Oxygenator models included EUROSETS Alone, Maquet PLS, Paragon, Terumo Fx15, and Quadrox-i. Frequent adjustments to ECMO parameters, infection control, and daily rehabilitation efforts were essential components of care. Weaning tests consistently indicated no recovery of cardiac function.

Despite rigorous management, the oxygenators faced performance declines over time, including clotting, reduced oxygen exchange, and lower CO₂ removal efficiency, necessitating frequent replacements, with a total of ten changes across the ECMO course. Oxygenator usage durations were as follows: EUROSETS (10, 32, 88, and 26 days), Paragon (78 days), Maquet PLS (14 days), Terumo Fx15 (5, 1, 3, and 2 days), and Quadrox-i (1 day). Notably, EUROSETS nr 3 achieved the longest duration of 88 days, while the Paragon oxygenator provided stable support for 78 days. In contrast, the Maquet PLS oxygenator lasted 14 days, and the Terumo Fx15 and Quadrox-i models required rapid replacement within 1-5 days due to accelerated wear and reduced efficacy. Ultimately, ECMO support was discontinued due to irreversible heart failure, with limited options for heart-lung transplantation in Ukraine's conflict-impacted healthcare system. The patient passed away following the cessation of ECMO support due to severe multi-organ dysfunction and complications.

This case underscores the extraordinary challenges of prolonged ECMO use in a pediatric patient within a war zone, highlighting the resilience and adaptability required of healthcare teams in resource-limited settings. The logistical constraints imposed by a lack of suitable biomedical devices and the necessity to use suboptimal models due to supply shortages emphasize the need for international support and resource mobilization to sustain advanced medical care in conflict-affected regions.