Abstract Body (Do not enter title and authors here): Background
Refractory cardiac arrest secondary to STEMI carries a high risk of mortality, particularly when ROSC is transient or unsustainable. Early extracorporeal cardiopulmonary resuscitation (ECPR) using VA ECMO offers a potential survival strategy in select patients with reversible causes of arrest.

Case
A 55-year-old woman with hypertension and hyperlipidemia experienced acute chest pain while attending a church event. En route to a nearby fire station, she lost consciousness. Upon arrival, fire department personnel initiated CPR and successfully defibrillated her, achieving ROSC. She was transported to a community hospital, where she experienced recurrent arrest. After brief ROSC, she was emergently airlifted to our quaternary care center. Upon arrival, she was pulseless and unresponsive. Despite 30 minutes of ACLS, ROSC was not achieved, prompting rapid ECPR initiation with VA ECMO cannulation in the emergency department. She was subsequently admitted to the Cardiopulmonary Critical Care Unit (CPCC) on full mechanical and pharmacologic support, including targeted temperature management. The following day, an IABP was placed at the bedside in CPCC to reduce afterload and increase coronary perfusion.

Decision-Making
ECG revealed inferior STEMI with Q waves; echocardiogram showed EF 20–25%. Initial lab results demonstrated a pH of 7.13, lactate of 12.7 mmol/L, WBC 13.82K, AST/ALT 931/771 IU/L, and creatinine of 1.4. Given profound hemodynamic instability and multi-organ involvement, coronary angiography and PCI were deliberately deferred to prioritize stabilization and organ support. While on ECMO support, she developed hemoperitoneum requiring embolization, right lower extremity ischemia requiring thrombectomy, complete heart block requiring temporary pacing (TVP), and acute kidney injury requiring CRRT. ECMO support was discontinued on Day 4, with subsequent removal of IABP and TVP on Days 9 and 10, respectively. She was extubated on Day 20. Following 47 days of hospitalization, she discharged home with PT/OT.

Conclusion
This case demonstrates that early ECPR deployment in patients with reversible cardiac arrest and STEMI can facilitate survival and meaningful recovery. Despite recurrent cardiac arrest, profound shock, and multisystem complications, this patient achieved full recovery through ECPR and multidisciplinary critical care. Post-discharge, renal function normalized, dialysis access was removed, and she successfully underwent PCI two months later.