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such as damaged infrastructure , restricted transportation , and interrupted international support . These limitations drastically affect the provision of complex and resource-intensive care , especially for vulnerable populations like pediatric patients who require specialized interventions . The need for durable , reliable medical devices is especially critical under such conditions , where resource scarcity makes frequent replacements or repairs nearly impossible [ 1 ]. This necessity is particularly pronounced for life-sustaining interventions such as extracorporeal membrane oxygenation ( ECMO ), which requires robust oxygenator performance to ensure patient survival over extended periods . In a stable setting , ECMO systems rely on high-quality , long-lasting devices to maintain consistent gas exchange and minimize complications [ 2 ]. However , in Kyiv ’ s war-torn environment , access to the most advanced and durable devices is significantly restricted . Limited availability has led to the use of suboptimal devices , such as polypropylene fiber oxygenators ( Quadrox-i and Terumo Fx15 models ), which , while effective in the short-term , are not recommended for long-term use due to their tendency for rapid wear and reduced efficiency in oxygen exchange and CO 2 removal . These forced compromises in device selection underscore the critical need for efficient and durable biomedical equipment in conflict settings , where routine maintenance and device replacement can be prohibitively challenging . In the absence of reliable supply chains , healthcare providers are often unable to replace malfunctioning devices promptly , which can lead to increased patient risk [ 1 ]. The frequent device failures associated with using less durable equipment strain limited resources , as each oxygenator replacement requires additional time , technical expertise , and materials that are in short supply . This report details the case of a 12-year-old girl with severe congenital heart disease and myocarditis , who underwent prolonged ECMO support for 259 days in Kyiv amidst these constraints . Her case highlights the extraordinary challenges faced by healthcare providers in sustaining ECMO support in a setting with significant supply limitations , where barriers to obtaining efficient and durable medical equipment greatly impacted patient care and outcomes . The experience reflects the broader need for international collaboration and support in supplying conflict-affected healthcare systems with the necessary resources to deliver complex , life-sustaining care amidst persistent logistical and resource challenges .
Materials and methods Patient information
The patient was a 12-year-old girl , height 144 cm , weight 25 kg , and body surface area ( BSA ) 1.4 m 2 , with severe congenital heart disease . Her diagnosis included critical aortic valve stenosis with a mono-cuspid aortic valve , moderate mitral valve insufficiency , and a partial anomalous pulmonary venous connection ( right superior pulmonary vein connected to the superior vena cava ). She presented with severe heart failure , indicated by an ejection fraction of 17 %, acute myocarditis , acute respiratory distress syndrome ( ARDS ), pneumonia , bilateral hydrothorax , and ascites . Upon transfer to our clinic on
January 28 , 2024 , her critical status necessitated immediate interventions . Two endovascular balloon valvuloplasties were performed early on January 29 , with minimal improvement . By evening , with a Murray score of 3.25 , VV-ECMO was initiated to stabilize her respiratory and cardiac function . Shortly after , she tested positive for Influenza A , further complicating her condition . Over the next few days , her condition remained critical . Additional treatments , including continuous renal replacement therapy ( CRRT ) and inotropic support optimization , were implemented . Given her declining hemodynamics , she underwent aortic valve replacement with a mechanical prosthesis , followed by a shift to VA-ECMO due to worsening cardiac function . Myocardial biopsy confirmed myocarditis , leading to her placement on the heart-lung transplant waiting list . Unfortunately , the absence of compatible donors due to logistical constraints prevented any further transplantation interventions . This study was conducted in accordance with the ethical standards of the institutional and national research committee . Approval for this study and its publication was obtained from the Internal Institutional Review Board ( IRB ), ensuring all ethical concerns regarding patient treatment and data confidentiality were thoroughly addressed . The manuscript has been checked for conflicts of interest , and none were found that could affect the integrity of the research .
Operative plan The ECMO course for this 12-year-old patient spanned a prolonged and complex 259 days , necessitated by severe respiratory and cardiac complications and marked by frequent adjustments to both the ECMO configuration and oxygenator components . Initially , VV-ECMO ( Femoral vein Maquet 23Fr and Jugular vein HLS 19Fr ), was initiated on January 29 , 2024 , due to the patient ’ s respiratory distress and hemodynamic instability . Given the persistence of cardiac compromise and eventual deterioration in hemodynamics , the ECMO was transitioned to VA-ECMO on February 8 , 2024 . Cannulation for VA-ECMO involved the use of a Maquet 23F cannula for drainage in the right internal jugular vein and an ALS 17F cannula for arterial return in the common carotid artery , utilizing a vascular prosthesis . These adjustments allowed for greater support to both the heart and lungs throughout the ECMO course , with additional modifications made as required by the patient ’ s evolving condition . The patient ’ s clinical history included congenital heart disease with severe aortic valve stenosis , moderate mitral valve insufficiency , partial anomalous pulmonary venous connection , and advanced heart failure ( EF LV-17 %). She had been hospitalized on January 28 , 2024 , with a suspected diagnosis of acute myocarditis , alongside ARDS , bilateral pneumonia , and complications such as hydrothorax and ascites . Influenza A was also confirmed shortly after admission . Initial interventions included two endovascular balloon valvuloplasties on January 29 , 2024 , performed to relieve the severe aortic stenosis prior to ECMO initiation . Following ECMO initiation , a CRRT was introduced to manage fluid balance and optimize inotrope therapy . The patient underwent an aortic valve replacement ( AVR ) on February 2 , 2024 , during which the ECMO circuit was converted to cardiopulmonary bypass ( CPB ), and