44 D . Rusnak et al .: J Extra Corpor Technol 2025 , 57 , 42 – 49
throughout the ECMO support . Daily weaning tests were conducted , although all results remained negative . The pulmonary function recovered remarkably well despite multiple episodes of bleeding , confirmed by favorable pulmonary vein measurements during a subsequent angio-operation . However , the heart remained compromised with severely reduced function , reflected by a persistently low left ventricular outflow tract velocity time integral ( LVOT VTI ) and Ejection Fraction ( EF ), underscoring the need for a heart-lung transplant . Unfortunately , due to the limited transplant infrastructure in the country , compounded by the war ’ s impact , no suitable donor became available . On October 14 , 2024 , ECMO support was discontinued following system dysfunction and deteriorating patient stability . Despite the extensive , multidisciplinary effort to sustain this young patient , she ultimately succumbed to multiorgan dysfunction secondary to her underlying cardiac failure .
Management of anticoagulation and blood products
Figure 1 . Patient Rehabilitation during VA ECMO .
a myocardium biopsy confirmed myocarditis . As part of longterm respiratory support , a tracheostomy was performed on February 13 , 2024 . The patient was also managed on ECMOawake protocols , engaging in daily mobilization and rehabilitation , which included ambulation within the hospital , despite being on ECMO support ( Figure 1 ). Supply shortages during the conflict in Kyiv necessitated the use of polypropylene-based oxygenators ( such as Quadrox-i and Terumo Fx15 ), which are typically unsuitable for long-term ECMO due to their propensity for premature failure . This led to an increased frequency of oxygenator replacements , totaling ten changes over the course of treatment . The EUROSETS oxygenators demonstrated relatively prolonged usage durations , and low levels of plasma free hemoglobin ( Table 1 ), including the longest span of 88 days with Eurosets oxygenator nr 3 , while Terumo Fx15 oxygenators had to be replaced within a maximum of 2 days due to high transmembrane pressures . Later in the course , PLS Quadrox and Paragon PMP oxygenators were used , with Paragon sustaining usage for 79 days . Regular adjustments to the ECMO circuit were also essential , including a complete circuit and cannula replacement on June 7 , 2024 , due to extensive thrombosis and mechanical complications . On July 3 , 2024 , the patient experienced acute thrombosis of the oxygenator , requiring immediate replacement with a Terumo Fx15 unit , and further replacements were subsequently made . The ECMO was operated in VA-ECMO mode with flows between 2000 and 2300 mL / min . Typical pressure readings included pre-oxygenator pressures of 220 mmHg , post-oxygenator pressures of 185 mmHg , and venous pressures around 30 mmHg . Maximum lactate levels reached 6 mmol / L , reflecting the patient ’ s metabolic status
At our center , patients undergoing ECMO therapy are managed with a continuous infusion of heparin . The target for activated partial thromboplastin time ( aPTT ) is set between 50 s and 65 s , unless specific clinical conditions , such as active bleeding , necessitate alternative parameters . The heparin dose is adjusted using a nurse-driven protocol based on a nomogram . This approach considers the patient ’ s weight to determine the initial infusion rate . An aPTT measurement is obtained six hours after starting the infusion . Based on the result , the infusion rate is modified : increased if the aPTT is below 50 s , decreased if above 65 s , or maintained if within the target range . Subsequent aPTT checks are performed every 6 h until two consecutive results are within the target range , after which daily monitoring is instituted . For platelet management , the standard practice at our institution involves transfusion when platelet counts drop below 80,000 / lL . However , some advanced centers adopt a more conservative threshold , intervening only when levels fall to 40,000 – 50,000 / lL or as low as 20,000 / lL in patients who are not actively bleeding . Red blood cell transfusion strategies vary based on hemoglobin ( Hb ) levels and physiological factors such as blood flow ( BF ), cardiac output ( CO ), and oxygen delivery ( DO 2 ). Restrictive transfusion protocols are applied when Hb levels fall within 7 – 9 g / dL , whereas a more liberal approach is taken for Hb levels of 10 – 12 g / dL [ 9 ]. In this case report , the restrictive blood transfusion protocol was implemented driven by the need to conserve scarce resources highlights the dire supply situation that dictates every aspect of ECMO management in a conflict-affected setting .
Results
Throughout the 259-day ECMO course , a total of 11 oxygenators were utilized to sustain this young patient , each adapted to manage the complexities of her prolonged treatment . These included four EUROSETS Alone Polymethylpentene ( PMP ), the Maquet PLS , Paragon PMP , four Terumo Fx15 oxygenators , and a Quadrox-i . Due to the extraordinary duration of ECMO support and the frequent complications