9: Successful Outcome of VA-ECMO in Intra-operative Ventricular Electrical Storm with Genetic Predisposition and Refractory to Multiple Defibrillations

Background: Treatment-resistant Ventricular Electrical Storms (VES) are dramatic, life-threatening arrhythmias that pose significant management challenges in the background of cardiac arrest and cardiogenic shock. The risks are heightened in hereditary arrhythmic conditions, particularly for those who are unaware of their predisposition and unprotected by implantable cardioverter Defibrillators (ICDs). Intraoperative VES is even more rare and could possibly be triggered by electrocautery or anesthetics. Herein we present a unique case of an intraoperative VES unresponsive to nearly 250 defibrillation attempts—one of the highest encountered in our clinical practice! Initiating lifesaving VA-ECMO just hours after the initial cardiac arrest served effectively as an extended ECPR to stabilize our patient. Case Report: A previously healthy 40-year-old mother of three was admitted for an elective myomectomy for multiple fibroids. Intraoperatively, she suffered cardiac arrest and developed refractory VF, unresponsive to pharmacological intervention and initial defibrillator shocks. Subsequent family history revealed two siblings who died from sudden cardiac deaths and a sister who experienced VF during a myomectomy. Her condition deteriorated to cardiogenic shock, evidenced by reduced EF and increased inotropic support. Emergency VA-ECMO was initiated, and an IABP was placed for further stabilization. The patient was transferred to our center and underwent 250 defibrillation attempts. Five days later, her ejection fraction normalized, allowing for decannulation, IABP removal, and extubation. She experienced additional VF after emergency laparotomy for a burst abdomen under spinal anesthesia, which were terminated. She eventually received an ICD and was discharged in stable condition. Further electrophysiological study and possible catheter ablation are being considered. Conclusion: The possible hereditary cause and intra-operative trigger of this patient’s VES are unique to the case and require further investigation. Initiating VA-ECMO as extended E-CPR was critical in stabilizing an otherwise unresponsive patient, bridging the gap to definitive treatment and significantly reducing mortality.