48 D . Rusnak et al .: J Extra Corpor Technol 2025 , 57 , 42 – 49
where logistical and material limitations compound the complexity of advanced medical care . The patient ’ s clinical course was complicated by underlying congenital heart disease , including severe aortic stenosis , and additional acute conditions such as myocarditis , respiratory distress , and bilateral pneumonia . The chronic nature of her cardiac dysfunction , combined with the war-impacted healthcare infrastructure , imposed substantial limitations on treatment options , most notably the lack of viable transplant alternatives [ 1 , 2 , 9 ]. The ECMO course involved several significant adaptations , including multiple transitions in ECMO configuration to match the patient ’ s shifting hemodynamic needs . Starting with VV-ECMO to support respiratory function , the configuration was converted to VA-ECMO as cardiac function deteriorated . This adaptability in ECMO configuration was critical for sustaining the patient over the extended treatment period , despite the associated risks and complications with each change [ 3 ]. Nevertheless , the prolonged duration of VA-ECMO support underscores the severity and persistence of her cardiac dysfunction , which was ultimately refractory to all attempts at weaning . The war-driven scarcity of medical supplies introduced unique challenges to ECMO management . Due to supply chain disruptions , the medical team was forced to use polypropylene-based oxygenators , including Quadrox-i and Terumo Fx15 , which are generally unsuitable for long-term use due to the increased risk of clot formation [ 4 , 5 ]. These oxygenators required frequent replacements due to mechanical failure , leading to increased procedural risks and heightened resource consumption . EUROSETS oxygenators demonstrated relatively better performance in terms of duration , with one oxygenator lasting up to 88 days . However , the frequent need for replacements underscores the limitations imposed by the lack of specialized , long-term ECMOcompatible oxygenators , and the extraordinary lengths the team had to go to adapt to the circumstances . Thrombosis and bleeding complications were recurrent throughout the ECMO course . High transmembrane pressures , indicative of clot formation , necessitated circuit and oxygenator replacements , while bleeding events such as pulmonary hemorrhage and epistaxis required intensive management [ 6 , 7 ]. The patient developed hemorrhagic complications that escalated into a critical pulmonary hemorrhage on July 9 , 2024 , requiring selective bronchial occlusion to achieve hemostasis [ 8 , 9 ]. These events were exacerbated by the absence of heparin during specific periods , a precaution taken to manage the bleeding [ 10 , 11 ]. The frequent circuit changes , particularly in a setting where optimal ECMO equipment was not consistently available , further illustrate the complex interplay of thrombosis and bleeding management in prolonged ECMO support . Despite repeated attempts , weaning from ECMO was unsuccessful . Pulmonary function showed significant recovery , evidenced by normal PaCO 2 and high PaO 2 levels in subsequent tests , but cardiac function remained critically compromised [ 12 ]. The patient ’ s heart continued to exhibit severe dysfunction with a low EF , LVOT VTI , and other metrics indicating minimal contractile capacity . Although a heart-lung transplant was theoretically the best solution , the lack of a compatible donor and the limited transplant infrastructure in Ukraine , especially during wartime , rendered this option unfeasible . This limitation emphasizes the critical role that accessible transplantation services play in the management of end-stage organ failure and highlights the impact of conflict on healthcare resources and patient outcomes . In the challenging wartime context of Ukraine , ECMO therapy poses a unique set of logistical and medical hurdles , particularly concerning the availability of anticoagulants and advanced medical devices . Heparin remains the primary anticoagulant used in pediatric patients due to its relative availability , despite Bivalirudin being a preferable alternative for its reduced bleeding risk . Unfortunately , the latter is scarcely available and economically unfeasible given the current circumstances . Additionally , the use of advanced devices like the Pedimag ( Levotronix ) as a bridge to transplant was explored but remains inaccessible due to severe limitations in supply chains and financial constraints . These issues extend to the challenges of arranging patient transfers for transplantation to neighboring countries such as Latvia , Lithuania , or Poland , which are complicated by bureaucratic barriers , logistical difficulties , and the unpredictability of safe transport routes .
Limitations
The data presented in this study also possess inherent limitations that must be acknowledged . The analysis is based on a single case , which limits the statistical power and broader applicability of the findings . Additionally , due to the exigencies of war , data collection was subject to interruptions and inconsistencies , potentially leading to gaps or biases in the recorded information . The reliance on a limited range of oxygenators , dictated by availability rather than optimal choice , may have influenced the outcomes and the subsequent analysis . Furthermore , the emergency nature of medical interventions during the conflict may have compromised the precision and reliability of clinical measurements , introducing an element of uncertainty in evaluating the efficacy of ECMO support . Recognizing these data limitations is crucial for interpreting the study ’ s conclusions and for planning future research in similar settings . The case illustrates the resilience and adaptability required from healthcare providers managing complex , high-risk treatments in conflict settings . The team ’ s capacity to maintain ECMO support for such an extended period , despite equipment shortages , frequent circuit and oxygenator replacements , and recurrent complications , demonstrates remarkable commitment to sustaining life [ 8 , 9 ]. This case also underscores the pressing need for robust , war-resilient healthcare supply chains that can support advanced therapies , including ECMO , under adverse conditions . In conclusion , this case highlights both the technical challenges and the human resilience involved in managing prolonged ECMO in a conflict zone . Ultimately , the limitations imposed by the conflict environment significantly impacted the patient ’ s outcome , despite the best efforts of the medical team . Furthermore , the establishment of an international support system could significantly ameliorate the challenges faced in conflict zones . Such a system might include a collaborative network of healthcare providers , facilitated access to medical supplies via established logistics corridors , and shared guidelines for critical care practices . This support network could also incorporate training modules and real-time consultation services to assist local medical teams in managing complex cases with limited resources .