Time-critical VA-ECMO-facilitated resuscitation and recovery after acute myocardial infarction with cardiogenic shock and cardiac arrest: a case report

Abstract

Background Cardiogenic shock (CS) in the setting of acute myocardial infarction (AMI) remains associated with poor prognosis, with mortality of approximately 40%–50% despite mechanical circulatory support (MCS). Its prognostic value remains uncertain because AMI with CS involves complex pathophysiology requiring consideration of implantation timing, organ protection, functional recovery, and prevention of device-related and critical illness-related complications. Case summary A 36-year-old man with diabetes and hypertension was readmitted with recurrent chest pain 6 months after coronary stent implantation for acute anterior AMI. Initial electrocardiographic findings and rapid hemodynamic deterioration supported AMI complicated by CS. During emergency percutaneous coronary intervention, he developed refractory ventricular fibrillation (VF)/cardiac arrest (CA). Because the arrest occurred under in-hospital monitoring, chest compressions were initiated immediately, resulting in a no-flow interval of 0 min. A multidisciplinary extracorporeal cardiopulmonary resuscitation (ECPR) response was activated, and effective veno-arterial extracorporeal membrane oxygenation (VA-ECMO) flow was established 20 min after activation during ongoing cardiopulmonary resuscitation (CPR). This constituted ECPR rather than VA-ECMO after stable return of spontaneous circulation (ROSC), allowing right coronary artery revascularization with TIMI grade 3 flow. After VA-ECMO initiation, the early post-resuscitation course was complicated by weak arterial pulsatility, restricted aortic valve opening, persistent hyperlactatemia, pneumonia/airway infection, transient hyperosmolar disturbance, and suspected post-arrest hypoxic-ischemic encephalopathy. With multidisciplinary management, cardiac function improved, organ dysfunction partially recovered, and the patient was discharged on day 10 with a favorable neurological outcome, defined as Cerebral Performance Category (CPC) grade 1 and modified Rankin Scale (mRS) score 0. At 1 year, follow-up confirmed sustained functional recovery, patent previous stenting without significant restenosis, no progression of other coronary lesions, return to normal quality of life, and persistently favorable neurological status (CPC 1; mRS 0). Conclusion This case highlights the value of program-level ECPR readiness in selected patients with monitored AMI-related refractory CA during emergency percutaneous coronary intervention. A pre-primed ECMO pathway, immediate CPR, 0 min no-flow exposure, 20 min ECPR activation-to-flow interval, completed coronary reperfusion, and complication-focused multidisciplinary care contributed to this outcome. As a single case, these findings should be interpreted as hypothesis-generating rather than supporting unselective VA-ECMO use in AMI complicated by CS.