Successful extracorporeal cardiopulmonary resuscitation with percutaneous coronary intervention after nearly three hours of refractory out-of-hospital cardiac arrest: a case report.

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue strategy for refractory cardiac arrest. However, evidence supporting ECPR after extremely prolonged cardiopulmonary resuscitation (CPR) exceeding 150 min in non-hypothermic cardiac arrest remains exceedingly rare, and the upper time limit for initiating ECPR has not been definitively established. Case summary: A 52-year-old previously healthy male experienced out-of-hospital cardiac arrest (OHCA) with an initial rhythm of asystole that subsequently converted to a shockable rhythm. Following approximately 174 min of resuscitation with intermittent unstable return of spontaneous circulation (ROSC), venoarterial extracorporeal membrane oxygenation (VA-ECMO) was emergently initiated. The initial arterial pH was 7.083 with a lactate of 17.54 mmol/L. Coronary angiography revealed 95% stenosis of the proximal left anterior descending artery (LAD) with visible thrombus, and percutaneous coronary intervention (PCI) with drug-eluting stent implantation was performed under ECMO support, achieving TIMI grade 3 flow. An intra-aortic balloon pump (IABP) was placed for additional hemodynamic support. The patient developed acute kidney injury requiring continuous renal replacement therapy (CRRT). He was successfully weaned from ECMO on day 3, regained consciousness on day 4, was extubated on day 5, and was discharged on day 31 with a Cerebral Performance Category (CPC) score of 1 and a left ventricular ejection fraction (LVEF) of 49%. At 12-month follow-up, the patient remains in excellent health. Discussion: To our knowledge, this is one of the longest reported durations from cardiac arrest to ECMO initiation (∼174 min) in a non-hypothermic OHCA patient who achieved complete neurological recovery (CPC 1). This case challenges the prevailing paradigm that resuscitation beyond 60 min is futile and underscores the potential of ECPR combined with timely revascularization when favorable prognostic factors coexist.