Refractory cardiac arrest during epidural anesthesia for caesarean section in a patient with supra-systemic pulmonary hypertension rescued by VA ECMO

Patients with severe pulmonary arterial hypertension (PAH) tolerate the hemodynamic changes of pregnancy poorly and should be referred early to an experienced expert multidisciplinary team (MDT) in a tertiary care center early in pregnancy. Idiopathic pulmonary arterial hypertension, which is PAH without a known cause, is classified under group 1 of WHO classification of pulmonary hypertension. Current consensus guidelines and expert opinion recommend scheduled caesarean section under epidural anesthesia or combined low dose spinal-epidural anesthesia as the preferred mode of delivery and anesthesia in patients with PAH. However severe hemodynamic instability secondary to pulmonary hypertensive crises (PHC) or right ventricular failure can occur during the perioperative period and can precipitate refractory cardiac arrest. In this situation, timely institution of veno-arterial extracorporeal membrane oxygenation (VAECMO) can be lifesaving. Here we report the case of a patient with severe idiopathic PAH, who developed pulmonary hypertensive crisis, catecholamine-resistant hypotension and refractory cardiac arrest during establishment of epidural anesthesia for elective caesarean section, who was successfully rescued with VA ECMO.