C52-02 Refractory Ventricular Fibrillation Following Central Venous Catheter Placement: A Case of ECMO Salvaged Cardiac Arrest

Introduction Central venous catheter (CVC) insertion is a common and generally safe critical care procedure, yet ventricular fibrillation (VF) leading to cardiac arrest is exceedingly rare. Mechanical stimulation of the endocardium by a guidewire or catheter tip can provoke malignant arrhythmias, particularly in patients with structural heart disease or implanted cardiac devices. We present a case of iatrogenic VF arrest occurring immediately after right internal jugular (RIJ) CVC placement, successfully managed with veno-arterial-venous extracorporeal membrane oxygenation (V-AV ECMO). Case Presentation A 62-year-old man with coronary artery disease with prior percutaneous coronary intervention, ventricular tachycardia with dual-chamber ICD, atrial fibrillation, and polycythemia vera, presented with dyspnea and chest pain. On admission, he was tachypneic with elevated pro-BNP and leukocytosis. CT imaging showed mild pulmonary edema and small bilateral pleural effusions. Despite high-flow oxygen, his respiratory failure worsened, requiring intubation. During post-intubation hypotension, a RIJ CVC placement was attempted; however, after successful venous access and introduction of a 0.032-inch diameter guide wire inserted under ultrasound guidance, with needle and guidewire positions confirmed by two operators. Immediately after catheter advancement and guidewire removal, the patient developed VF arrest. Advanced cardiac life support (ACLS) and multiple defibrillations, including intrinsic ICD shocks, achieved return of spontaneous circulation (ROSC) after 15 minutes, followed by recurrent VF three minutes later. A second ACLS cycle restored ROSC after five minutes. Given refractory VF, the critical care and cardiothoracic teams initiated emergent Extracorporeal Cardio-Pulmonary Resuscitation, successfully initiating VA-ECMO via peripheral cannulation of the femoral vessels to achieve flows of (flow 3.2 L/min, sweep 5 L/min). Coronary angiography revealed patent stents and no new lesions. Remarkably, the patient was extubated within 24 hours, neurologically intact, transitioned from V-AV to VV-ECMO on day 4, and was decannulated on day 5. Discussion This case illustrates a rare but life-threatening complication of CVC placement. The presumed mechanism is mechanical stimulation of the right atrium or ventricle by the guidewire, triggering VF in a myocardium already vulnerable from ischemic cardiomyopathy and ICD leads. Rapid recognition and a multidisciplinary approach led to early initiation of ECMO, which was critical to survival. The patient’s full recovery highlights ECMO-assisted CPR’s role in achieving favorable outcomes in refractory, procedure-related VF. This abstract is funded by: None