Out-of-hospital cardiac arrest without return of spontaneous circulation after more than 2 hours: is termination of resuscitation the only option? A case report.

Background: Out-of-hospital cardiac arrest (OHCA) remains a major cause of mortality, with survival rates of approximately 8% despite timely cardiopulmonary resuscitation. While indications to initiate resuscitation are well established, decisions regarding termination remain complex, particularly in prolonged arrests with potentially reversible mechanisms. The routine application of termination-of-resuscitation rules may be limited by imperfect prognostic accuracy. Case summary: We report a previously healthy 20-year-old Caucasian man who suffered a witnessed OHCA with an initial shockable rhythm. Despite prolonged advanced life support and a total cardiac arrest duration of 135 min, venoarterial extracorporeal membrane oxygenation (ECMO) was initiated as a rescue therapy. Return of spontaneous circulation was achieved, followed by gradual haemodynamic stabilization and a complete neurological recovery. Extensive diagnostic evaluation excluded coronary artery disease, myocarditis, and structural cardiomyopathy. A diagnosis of primary ventricular fibrillation syndrome related to short-coupled ventricular premature complexes was established. A subcutaneous implantable cardioverter-defibrillator was implanted for secondary prevention. The patient was discharged without neurological or functional impairment and continued to be asymptomatic at the last visit. Discussion: This case highlights that meaningful recovery may be possible after prolonged resuscitation in carefully selected patients. It illustrates the potential role of ECMO in refractory OHCA and emphasizes the need for individualized decision-making when considering termination of resuscitative efforts, particularly in young patients with favourable initial characteristics.