37: Ventricular Tachyarrhythmia with Refractory VF and Severe Hypokalemia Managed with V-A ECMO

Background: Extracorporeal membrane oxygenation (ECMO), particularly veno-arterial (VA) ECMO, can serve as a rescue therapy for refractory ventricular arrhythmias associated with hemodynamic instability or cardiogenic shock. Refractory ventricular fibrillation (VF) secondary to excessive caffeine consumption is rare but potentially fatal. High doses of caffeine can precipitate malignant ventricular arrhythmias. We report a case of refractory VF successfully managed with VA-ECMO. Case Description: A 34-year-old male with no prior cardiac history presented with sudden onset diaphoresis followed by 30 minutes of unconsciousness. History revealed ingestion of a significant quantity of coffee beans. Initial evaluation demonstrated pleomorphic ventricular tachycardia with multiple QRS morphologies, severe metabolic acidosis, and profound hypokalemia. Despite correction of electrolyte abnormalities and multiple attempts at electrical cardioversion, the patient progressed to refractory VF. He was intubated, and ischemic etiology was excluded by coronary angiography. Pharmacological cardioversion with adenosine, lidocaine, and amiodarone infusion was unsuccessful. Intervention and Outcome: Peripheral VA-ECMO was initiated via femoral cannulation with an additional distal perfusion cannula. Initial ECMO settings included a flow of 2.4 L/min, pump speed of 3,140 RPM, and fraction of delivered oxygen (FiO2) of 100%. Hemodynamic parameters stabilized following ECMO initiation. Transthoracic echocardiography demonstrated preserved native cardiac function. Critical care management included standard ECMO protocols and anticoagulation with unfractionated heparin. The patient was successfully weaned from VA-ECMO. Hematemesis occurred post-weaning and was managed conservatively. Antiarrhythmic therapy was continued as supportive care, with no recurrence of malignant arrhythmias. Conclusion: Refractory ventricular arrhythmias in young patients without structural heart disease should prompt evaluation for toxicological etiologies. VA-ECMO can be lifesaving in cases of refractory VT/VF when conventional therapies fail. Successful outcomes depend on early initiation and coordinated multidisciplinary care.