When the heart stops or the lungs can no longer oxygenate the blood, time becomes the enemy to beat. And sometimes the obstinacy of doctors, supported by the most advanced technology, wins. This is what two recent stories tell, different in context but united by the same life-saving machinery: ECMO, extracorporeal membrane oxygenation. In Palermo, at the Civic hospital, a 19-year-old girl survived a cardiac arrest thanks to a heart massage prolonged for almost two hours and the timely use of extracorporeal circulation, which allowed her vital organs to be kept alive while the doctors worked to identify and treat the causes. In Milan, a young man was seriously burned during the Crans-Montana fire was supported with ECMO after a devastating trauma, when respiratory failure and systemic shock left no room for other treatment options.
Two extreme cases that show how ECMO is not a “miracle machine”, but a complex instrument capable of gaining precious time: hours, sometimes days, essential to allow the heart and lungs to recover or to allow life-saving interventions that would otherwise be impossible.
We talk to the about indications, limits and potential of this technology Dr. Vincenzo Mazzaresehead of the Anesthesia and Resuscitation department of the hospital ARNAS Civic of Palermowhose team – together with the doctors of the Emergency Department of the same hospital – followed the case of the young patient in cardiac arrest. A story that helps us understand when ECMO can make a difference and why it represents today one of the most advanced frontiers of emergency medicine.
Doctor Mazzarese, can you explain to us the case of this girl who was saved with a prolonged cardiac massage and subsequently with ECMO?
Yes, this girl came to us in the emergency room with a history of flu, a significant symptomatic flu. She had improved in the days before a trip to Lapland, but on her return the girl felt ill again, and one morning her mother found her unconscious in bed. She is then taken to the emergency room, and soon suffers cardiac arrest. This cardiac arrest is quickly dealt with by the doctors in the emergency room of the Civic hospital starting resuscitation maneuvers and the cardiologist is also called, because a pericardial effusion is highlighted which prevents the heart from pumping blood adequately. Although this pericardial effusion is evacuated, unfortunately the girl – with conventional resuscitation maneuvers – it did not resume its spontaneous heartbeatso he didn’t come out of cardiac arrest. We were then contacted, my colleagues and I who are part of the ECMO team, went to the emergency room (where in the meantime the cardiac massage continued for almost two hours) and we started ECMO treatment: after which the girl was admitted here to my intensive care unit, where she remained for about a fortnight. Little by little we managed to reduce the machine support, her heart reacted, we managed to wean her from mechanical and pharmacological supports and then we had the wonderful happy ending of being able to discharge her on Christmas Eve.
He said, in fact, that the cardiac massage was prolonged for a long time: how do you make this decision, why is it sometimes suspended early? What are the dynamics and what decisions need to be made?
Precisely at the end of 2025 they were published the guidelines of both American and European societies which concern basic and advanced cardiopulmonary resuscitation. There is no defined time. On average, if a patient does not respond to advanced conventional resuscitation maneuvers, it goes on for up to 20-30 minutes. Then they are suspended, because it is assumed that it no longer makes sense to continue to always administer the same drugs and perform cardiac massage in a patient who does not resume his spontaneous activity. Clearly this is an indicative time that depends on the age of the patient, the potential reversibility of the cause of cardiac arrestfrom many factors. In this case it continued from the conventional 20-30 minutes to 40-45, by virtue of the young age of the patient and the fact that there was a reversible cause underlying the arrest. Then the massage was continued while waiting to start the ECMO, because it is clear that it takes some technical time to be able to start the treatment, and in that situation it is necessary to ensure a flow of blood and oxygen to the brain and organs. This can only be ensured through cardiac massage and cardiopulmonary resuscitation.
Is the cardiac tamponade that you spoke about the only one of these reversible causes that pushes the resuscitators to continue or are there others?
The causes can be different. Among the reversible ones, for example, there is tension pneumothorax. In general, when the arrest is related to trauma -like pneumothorax, a pleural effusion, or a pericardial effusionas in this case – we are faced with a situation in which we can intervene: we can resolve the cause and think that the heart can start beating again. In these cases it makes sense to continue resuscitative maneuvers. The case of a cardiac arrest of which the cause is unknown is different, especially if it has not been witnessed: for example when it occurs on the street without anyone having witnessed the event and therefore appears sine causa. In these situations, after 20–30 minutes, the maneuvers are generally suspended.
So it is also important to have an exact understanding of when it started, whether there are witnesses or anything else. This can make a difference?
Absolutely yes. In this case it was a cardiac arrest that occurred in hospital, in our emergency area, where by definition patients are constantly monitored and followed by medical and nursing staff. A cardiac arrest that occurs at home or on the street is very different, without competent witnesses capable of understanding what is happening or, above all, of promptly initiating effective resuscitation measures.
Going into a little more detail, what exactly is ECMO and how does it differ from other forms of support? Basically, how does it work?
ECMO is a machine that can be used to support, or rather substitute, the activity of the heart or lungs. There are two types. When, as in this case, the problem is predominantly cardiological, the so-called veno-arterial ECMO is used: the machine takes blood from a large vein and reinfuses it into an arteryeffectively carrying out the function of the heart and guaranteeing a circulation that at that moment the heart is not able to ensure. There is then veno-venous ECMO, which has been talked about a lot during the Covid period, which instead serves to replace the function of the lungs. In this case the blood is taken from a vein and returned to another vein: the machine has the task of oxygenating it and eliminating carbon dioxide, carrying out exactly the work that the lungs would do. It’s about a complex extracorporeal machine, which requires highly specialized skills. Traditionally it is the prerogative of cardiac surgery departments and related resuscitations, but over time its use has also extended to multipurpose intensive care units, like ours. ECMO has taken on further importance in the context of what is defined as ECPR, i.e. extracorporeal cardiopulmonary resuscitation: when, as in our case, conventional resuscitation maneuvers are not effective, ECMO – if deemed indicated – truly represents the last chance to try to save the patient.
Is it a complicated process to equip yourself with an ECMO, have it in the hospital and train a dedicated team?
It’s a complex journey. First of all I must thank my management. In Italy, in fact, the ECMO service in the emergency room or in a multipurpose intensive care unit is not active in many hospitals. I had the desire to make this leap in quality, I proposed it to the strategic management and I must say that, thanks to their vision, they believed in the project. The general director and the health and administrative management put me in a position to start this journey, allowing me to hire five-six perfusionists – the technicians who physically manage the machine and who are fundamental figures – and to equip us with both the equipment and the necessary consumables. At the same time we have undertaken a long and demanding training course for medical and nursing staffanything but short or simple. But already with this event we have probably had confirmation that all the efforts and all the hard work we have put in have been rewarded.
However, it is an extremely advanced technology and, inevitably, also risky. What are the main risks?
He hit the point perfectly. ECMO represents the most complex and advanced attempt to save a patient with severe cardiorespiratory failure, but it is certainly not a zero-cost procedure. First of all it is necessary to insert two large cannulae into the vessels – femoral or jugular – to withdraw and reinfuse the blood, and already this maneuver in itself carries a high risk of complications. Furthermore, since the blood is circulated outside the body, the patient must be subjected to anticoagulant therapy: this exposes him to the risk of bleeding, including cerebral hemorrhage, which represents one of the most feared complications of ECMO, along with many other possible critical issues.
Was this girl’s case the first treated in your hospital since you introduced this procedure?
No, it wasn’t the first: if I remember correctly it was the second or third case. In reality we had been operational, with all the material necessary to implant an ECMO, since the beginning of November, therefore for a relatively short time. However, this was certainly the most complex case, because the operation was performed in an emergency area. It was possible thanks to an extraordinary collaboration: the emergency room doctors, us resuscitatorsthe cardiologist, the nurses, who were really great. In fact, it is one thing to insert an ECMO into your intensive care unit, it is another to organize a real ECMO team that moves like a mission to the emergency area to face the entire journey there.
This girl – if I’m not mistaken her name is Giada – also had a chain of lucky events. Nothing was taken for granted: it was not at all certain that he would arrive in the right emergency room, at the right time, finding a team ready and able to intervene.
Absolutely yes, as often happens in life Luck also plays a decisive role.
Did it get out safely?
Yes, yes. She’s back home and doing quite well. I felt it, because a very strong relationship of affection was created with the family: seeing a 19 year old girl saved from such a dramatic situation inevitably moved everyone. She’s home, she’s well, and I hope to see her again soon. I’m sure he’ll come visit us.
