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Published on: May 26, 2023
Pediatric ECPR as Bridge to Surgery: Successful Management of Refractory Cardiac Arrest in High-Risk ICD Lead
Jessy Steve Masso-Bueso1, Gian Manuel Jiménez-Rodríguez1, Kevin Alexis Fierros-Chablé2
1Interventional Cardiology Department Instituto Nacional de Cardiología Ignacio Chávez Mexico City Mexico.
Insights
Extracorporeal cardiopulmonary resuscitation (ECPR) can be a life-saving intervention for pediatric patients experiencing refractory cardiac arrest during procedures. This case demonstrates ECPR
Area of Science:
- Pediatric Cardiology
- Critical Care Medicine
- Cardiovascular Surgery
Background:
- Refractory cardiac arrest in children presents significant survival challenges.
- Extracorporeal cardiopulmonary resuscitation (ECPR) offers circulatory and respiratory support during cardiopulmonary resuscitation (CPR).
- Pediatric ECPR use is limited, with sparse evidence beyond case reports.
Purpose of the Study:
- To highlight the role of ECPR in a pediatric patient with refractory cardiac arrest during a high-risk intervention.
- To emphasize ECPR as a bridge to definitive repair in complex pediatric cases.
Main Methods:
- A 14-year-old female with dilated cardiomyopathy experienced refractory cardiac arrest during device maintenance.
- Emergent extracorporeal membrane oxygenation (ECMO) via percutaneous femoral veno-arterial cannulation was initiated.
- Surgical repair of atrial perforation and mechanical circulatory support were managed.
Main Results:
- ECPR successfully restored systemic perfusion and hemodynamic stability.
- The patient was decannulated on postoperative Day 1 and extubated without neurological deficits.
- Successful discharge to a heart transplant program was achieved.
Conclusions:
- ECPR is a critical bridge to definitive repair for pediatric refractory arrest during interventions.
- Early initiation, skilled cannulation, and multidisciplinary care are vital for survival.
- Further pediatric ECPR data are essential to refine criteria and expand its application.
Background:
Refractory cardiac arrest remains a major challenge in children, with poor survival despite advances in cardiopulmonary resuscitation (CPR). Extracorporeal cardiopulmonary resuscitation (ECPR), defined as rapid deployment of extracorporeal membrane oxygenation (ECMO) during ongoing CPR, provides circulatory and respiratory support and can serve as a bridge to definitive interventions. While increasingly reported in adults, pediatric use remains limited due to anatomical and physiological challenges, with evidence largely restricted to case reports and small series.
Case Presentation:
A 14-year-old female with dilated cardiomyopathy, severe left ventricular dysfunction (LVEF 12.5%), and prior implantable cardioverter-defibrillator placement underwent elective lead extraction and generator replacement. During the procedure, pericardial effusion with hemodynamic collapse occurred, requiring emergent pericardiocentesis. Despite transient return of spontaneous circulation, refractory cardiac arrest developed after 24 min of CPR. ECPR was initiated via percutaneous femoral veno-arterial ECMO, restoring systemic perfusion. Transesophageal echocardiography revealed right atrial perforation, which was surgically repaired. Hemodynamic stability was achieved with combined ECMO and intra-aortic balloon pump support. The patient was successfully decannulated on postoperative Day 1, extubated on Day 4 without neurological deficits, and discharged to a heart transplant program.
Conclusion:
This case highlights the pivotal role of ECPR as a bridge to definitive repair in pediatric patients experiencing refractory arrest during high-risk interventions. Early initiation, skilled cannulation, and multidisciplinary coordination were critical for survival. Pediatric experiences such as these are essential to refine selection criteria, inform procedural planning, and expand the limited evidence supporting ECPR as a transformative strategy in resuscitation for this vulnerable population.
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