Pediatric ECPR as Bridge to Surgery: Successful Management of Refractory Cardiac Arrest in High‐Risk ICD Lead Extraction

Background: Refractory cardiac arrest remains a major challenge in children, with poor survival despite advances in cardiopulmonary resuscitation (CPR). Extracorporeal cardiopulmonary resuscitation (ECPR), defined as rapid deployment of extracorporeal membrane oxygenation (ECMO) during ongoing CPR, provides circulatory and respiratory support and can serve as a bridge to definitive interventions. While increasingly reported in adults, pediatric use remains limited due to anatomical and physiological challenges, with evidence largely restricted to case reports and small series. Case Presentation: A 14-year-old female with dilated cardiomyopathy, severe left ventricular dysfunction (LVEF 12.5%), and prior implantable cardioverter-defibrillator placement underwent elective lead extraction and generator replacement. During the procedure, pericardial effusion with hemodynamic collapse occurred, requiring emergent pericardiocentesis. Despite transient return of spontaneous circulation, refractory cardiac arrest developed after 24 min of CPR. ECPR was initiated via percutaneous femoral veno-arterial ECMO, restoring systemic perfusion. Transesophageal echocardiography revealed right atrial perforation, which was surgically repaired. Hemodynamic stability was achieved with combined ECMO and intra-aortic balloon pump support. The patient was successfully decannulated on postoperative Day 1, extubated on Day 4 without neurological deficits, and discharged to a heart transplant program. Conclusion: This case highlights the pivotal role of ECPR as a bridge to definitive repair in pediatric patients experiencing refractory arrest during high-risk interventions. Early initiation, skilled cannulation, and multidisciplinary coordination were critical for survival. Pediatric experiences such as these are essential to refine selection criteria, inform procedural planning, and expand the limited evidence supporting ECPR as a transformative strategy in resuscitation for this vulnerable population.