When a patient becomes critically ill, time is the most precious resource.

Decisions must be made swiftly by doctors and families alike, in order to give the patient the best possible chance of survival.

Sometimes, the situation is so critical that only advanced life support can offer a final lifeline.

One such option is extracorporeal membrane oxygenation (ECMO).

This is a portable heart-and-lung machine used when both of the organs are no longer able to function adequately on their own.

ECMO works by taking blood out of the body, oxygenating it and removing carbon dioxide, then pumping the blood back in.

It temporarily takes over the work of the heart and lungs, allowing them to rest while doctors address the underlying cause of failure.

According to National Heart Institute (better known by its Malay acronym IJN) senior consultant cardiothoracic surgeon Prof Datuk Seri Dr Mohamed Ezani Md Taib, ECMO is a last-resort form of life support, reserved for patients with few remaining options.

“It supports the heart or lungs, and indirectly gives other organs a chance to recover, but only if the damage has not progressed too far,” he explains.

“Before ECMO is initiated, patients undergo careful assessment.”

Doctors evaluate heart function and review the condition of other vital organs, particularly the kidneys and liver.

“Not every patient is suitable,” he says.

Buying time for recovery

When the heart fails, other organs often follow.

“The lungs, kidneys and liver are usually affected first,” Dr Mohamed Ezani says.

This cascade was seen in the case of a 22-year-old student from China who was treated at IJN recently.

His illness began with a high fever, suspected to be a viral infection, possibly dengue.

Despite seeing a general practitioner (GP), he become more ill and was admitted to a private hospital.

His condition worsened to the point where he had to be intubated and placed on a ventilator.

The doctors also soon discovered that his heart function was severely impaired.

Despite multiple medications, his condition deteriorated further, and his kidneys and liver began to fail.

“At that point, the doctors were running out of options and contacted our team to see if further support was possible,” Dr Mohamed Ezani says.

After reviewing the case, the IJN team suspected the student had viral myocarditis.

This is a rare condition where a viral infection triggers sudden and severe inflammation of the heart.

“Certain viruses, including influenza, can cause acute heart failure,” he explains.

“Many patients do not survive, or eventually require a heart transplant or long-term mechanical support.

“However, with timely intervention, the heart can sometimes recover.”

Given the severity of the case, the team decided to put the student on ECMO to support both his heart and lungs.

The response was almost immediate.

His blood pressure stabilised, his heart rate improved, and his medications could be decreased.

Within 48 hours, he began to regain consciousness.

“In young patients, heart function can improve within three days to a week, while in older patients, it will take a longer time,” Dr Mohamed Ezani notes.

By the fifth day, the student was showing significant recovery.

He was successfully taken off ECMO and his heart resumed independent function.

He did, however, have to remain on a ventilator, having not breathed on his own for more than a week.

Two days later, his breathing tube was also removed.

With ongoing medical care and physiotherapy, he continues to improve and is expected to eventually be well enough to return to China.

His family, previously told they might lose him, were deeply grateful to the medical team.

“This case shows that not all hope is lost,” Dr Mohamed Ezani says.

“If patients are referred at the right time, we may still be able to help.”

Expertise matters

Outcomes depend not just on access to ECMO, but also on how it is used.

“Many centres can purchase the equipment, but experience is what truly makes the difference,” says Dr Mohamed Ezani, who is also the chief executive officer of IJN.

“Knowing when to start ECMO, how to manage it and when to withdraw support requires constant reassessment, sound clinical judgement and a highly-trained team.”

That team includes specialist nurses and heart-lung technicians, also known as perfusionists, who manage blood flow and volume during ECMO support.

“You cannot simply buy the machine and expect to use it safely,” he says.

“That level of judgement comes from years of experience.”

At IJN, ECMO has been used for many years.

It was initially for patients who developed severe heart failure after cardiac surgery.

Over time, the team has refined its approach, carefully balancing the patient’s own heart function with mechanical support.

“ECMO is infrastructure,” says consultant anaesthesiologist and intensivist, and IJN Anaes-thesia and Intensive Care deputy head Datuk Dr Suneta Sulaiman.

“But what really matters is treating the underlying disease and managing the patient’s overall condition.

“With a strong multidisciplinary team and extensive experience managing critically ill patients, the institute now encourages early referrals in suitable cases.”

Currently, the government hospitals with ECMO capabilities include Hospital Sultan Idris Shah in Serdang, Selangor; Penang General Hospital in Georgetown; and Sarawak Heart Centre in Kuching.

Availability in the private sector remains limited.

Dr Mohamad Ezani and Dr Suneta were speaking to the press during a media briefing on ECMO.