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IntroductionPersistent asystole following restoration of mechanical circulation during extracorporeal cardiopulmonary resuscitation (E-CPR) is typically considered fatal. However, in profound hypothermia, electrical silence may not reflect irreversible myocardial injury.Case ReportA term neonate with severe meconium aspiration syndrome (MAS) was initially supported on veno-arterial ECMO at a regional hospital and transported to a tertiary ECMO facility. Following decannulation, she suffered cardiac arrest. Mechanical circulation was achieved after prolonged E-CPR with central cannulation, but the patient remained asystolic in the context of profound hypothermia (31.2°C). Electrical activity reappeared only after controlled rewarming to 33°C. She was discharged home on day 35 with a good long term neurological outcome.DiscussionNeonates are particularly prone to rapid hypothermia during resuscitation. Controlled rewarming is essential to determine cardiac viability before establishing futility.ConclusionUnder profound hypothermia, asystole after restoration of mechanical circulation does not preclude irreversible myocardial damage. Cautious rewarming is mandatory to assess myocardial prognosis.