# Case Report of Successful Extracorporeal CPR (eCPR) in Refractory Cardiac Arrest Caused by Fulminant Pulmonary Embolism with Remarkable Recovery

## TL;DR

A 66-year-old woman survived a severe heart attack caused by a massive blood clot in her lungs after receiving a special life-support treatment called eCPR.

## Contribution

This case report demonstrates successful eCPR in a patient with refractory cardiac arrest due to massive pulmonary embolism and poor initial prognosis.

## Key findings

- Extracorporeal CPR (eCPR) enabled survival and full neurological recovery in a patient with severe acidosis and high lactate levels.
- Multidisciplinary management, including surgical thrombectomy, was crucial for successful outcomes.
- eCPR can lead to favorable outcomes even in cases with poor initial prognostic indicators.

## Abstract

Background and Clinical Significance: Fulminant pulmonary embolism (PE) leading to an out-of-hospital cardiac arrest (OHCA) is associated with a high mortality rate and cardiopulmonary resuscitation (CPR) frequently failing to achieve return of spontaneous circulation (ROSC). Extracorporeal CPR (eCPR) has emerged as a potential life-saving intervention. Case Presentation: A 66-year-old woman suffered an OHCA due to massive PE, presenting with pulseless electrical activity (PEA). After 90 min of pre- and in-hospital CPR without sustained ROSC, venoarterial extracorporeal membrane oxygenation (va-ECMO) was initiated as eCPR upon arrival at the hospital. Even after implantation of the va-ECMO, there was initially a pronounced acidosis (pH 6.9) with a high elevated lactate level (>30 mmol/L); these factors, together with the prolonged low-flow period, indicated a poor prognosis. Further diagnostic tests revealed intracranial hemorrhage (subdural hematoma), and systemic lysis was not possible. With persistent right heart failure, surgical thrombectomy was performed during hospitalization. Intensive multidisciplinary management finally led to successful therapy and weaning from mechanical ventilation, as well as to complete neurological recovery (CPC-Score 1-2). Conclusions: This case illustrates that eCPR can facilitate survival with good favorable neurological outcomes despite initially poor prognostic predictors. It underscores the importance of refining patient selection criteria and optimizing management strategies for eCPR in refractory cardiac arrest secondary to PE.