Anthony was placed on VA ECMO via percutaneous femoral access, and underwent 60 minutes of CPR prior to the establishment of support. He was cooled to 34 degrees C per ECPR protocol and taken to the cardiac cath lab for a successful percutaneous embolectomy. For the first 12 hours in the ICU his pupils remained fixed and dilated, but then became reactive. His sedation had been stopped to allow proper neurologic assessment. The next day his cardiac function was excellent allowing weaning of the ECMO flow. He began moving his extremities and had a few episodes of myoclonic jerking for which he was started on Kepra. By the next morning he was awake, alert, and following commands. At 48 hours of support he was slowly warmed back to normothermia. His perfusion was excellent, kidneys were functioning well, the lactate was normal and so he was started on tube feedings. He was decannulated from ECMO two days later and was discharged to home once his coumadin was therapeutic, after a full neurological recovery.

Some additional points about Anthony:

• Quality of CPR and the presence of some gas exchange is much more important than the length of time of the resuscitation.

• Fixed and dilated pupils are not a good measure of the quality of CPR. Reactive pupils are great, but absence of reactivity is not uncommon during CPR in ultimate survivors.

• This patient was taken for a percutaneous embolectomy, but other treatment options are also valid depending on the patient specifics and the providers’ skillsets and experience. These include surgical embolectomy, or observation and re-evaluation to see what effect the alteplase had while on ECMO support. Often if the thrombus is “fresh” and not chronic, the fibrinolysis activated by exposure to the ECMO circuit (primarily the oxygenator) is sufficient to initiate clot lysis, without administering tPA, and along with systemic heparin.