Never say never: successful extracorporeal cardiopulmonary resuscitation (ECPR) following a prolonged out-of-hospital cardiac arrest due to spontaneous coronary artery dissection

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Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be a life-saving rescue therapy for patients with severe cardiac disease of any origin and circulatory failure. Data in the literature have demonstrated that the use of advanced mechanical circulation has resulted in improvements in both survival and quality of life; despite this, cardiogenic shock and refractory cardiac arrest remain conditions with high mortality. Opportune identification of patients who can benefit from it may improve outcomes. However, the shortage of guidelines on indications often results in a high mortality rate and poor outcome. Due to ethical issues, randomised controlled studies with VA-ECMO have not been conducted so no recommended evidence-based guidelines exist for VA-ECMO patient-selection criteria. Therefore, the indications depend only on expert opinion after reviewing the literature. Case description: We report the case of a young female patient who presented with an out-of-hospital cardiac arrest (OHCA) due to spontaneous coronary dissection. She was treated with extracorporeal cardiopulmonary resuscitation (ECPR) with excellent results in terms of short and long-term survival, and neurological outcome. This was despite the presence of several clinical and laboratory negative prognostic factors on the basis of the current literature, and the lack of general consensus among the relevant medical personnel. Conclusion: We were able to explain the favourable outcome only on the basis of clinical data. We can conclude that the availability of advanced resources in the area (timeliness of the rescues, quality of the resuscitation, an advanced haemodynamic management centre nearby) has contributed to determining the complete clinical and neurological recovery of the patient. LEARNING POINTS: Extracorporeal cardiopulmonary resuscitation to rescue patients with cardiac arrest refractory to conventional cardiopulmonary resuscitation could represent a life-saving technique in carefully selected patients.Refractory out-of-hospital cardiac arrest with evolution to a non-shockable rhythm and severe lactic acidosis are conditions that should not rule out ECPR.Evidence-based selection of ECPR patients remains challenging, but it could be considered as a therapeutic option in dedicated specialised centres.

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