Refractory ventricular arrhythmias and cardiac arrest in younger patients are rare, life-threatening events, particularly when standard resuscitation fails. Extracorporeal membrane oxygenation (ECMO) provides temporary circulatory support, enabling hemodynamic stabilization, myocardial recovery, and time for diagnostic and therapeutic interventions.

We report the case of a 40-year-old East African woman, medically free at baseline, who developed refractory ventricular fibrillation (VF) and cardiogenic shock during elective myomectomy on 12^th August 2024. She underwent 45 minutes of cardiopulmonary resuscitation (CPR) before the return of spontaneous circulation. Echocardiography revealed severe left ventricular (LV) dysfunction with an ejection fraction (EF) of approximately 10%. Veno-arterial ECMO (VA-ECMO) was initiated 15 hours after the first VF episode on 13^th August 2024 per institutional protocols; support continued for six days until 19^th August 2024. During ECMO, coronary assessment, continuous rhythm monitoring, and serial echocardiography were performed to guide management and systematically exclude reversible causes, including ischemia, myocarditis, embolic events, and electrolyte disturbances. An intra-aortic balloon pump (IABP) was added on 14^th August 2024 and removed on 20^th August 2024.

Post-event discussions revealed a previously unrecognized strong family history of sudden cardiac death. Despite maximal antiarrhythmic therapy, recurrent VF and nonsustained ventricular tachycardia (VT) persisted. A temporary pacemaker was inserted on 30^th August 2024, and an implantable cardioverter-defibrillator (ICD) was placed for secondary prevention, risk stratification, and management of persistent diagnostic uncertainty. Genetic testing was performed due to the newly discovered family history, including a long QT gene panel (ordered 5^th September 2024, reported 31^st October 2024) and proband whole exome sequencing (WES; ordered 5^th September 2024, reported 27^th February 2025). WES identified a heterozygous likely pathogenic variant in the AIP gene and two variants of uncertain significance in TTN, while the long QT panel was negative; none fully explained the arrhythmia. Familial screening and clinical correlation were recommended.

The patient achieved full recovery, with normalization of cardiac function and improved strain parameters by hospital discharge. This case highlights VA-ECMO as a bridge to myocardial recovery in refractory arrhythmias, underscores systematic exclusion of reversible triggers, and demonstrates that combined ECMO, IABP, and ICD therapy can be life-saving in preventing recurrent cardiac arrest and sudden cardiac death.