ECPR may be the most effective intervention for refractory cardiac arrest—ever

Abstract

Among treatments for patients with refractory cardiac arrest, the application of extracorporeal membrane oxygenation—known as extracorporeal cardiopulmonary resuscitation (ECPR)—is arguably the most effective intervention for refractory cardiac arrest—ever. Indeed, data from two recent randomized clinical trials (ARREST 1. Yannopoulos D. Bartos J. Raveendran G. Walser E. Connett J. Murray T.A. et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. The Lancet. 2020; Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar and Prague OHCA 2. Belohlavek J. Smalcova J. Rob D. Franek O. Smid O. Pokorna M. et al. Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2022; 327: 737-747 Crossref PubMed Scopus (30) Google Scholar show that for patients with refractory ventricular fibrillation, having an out of hospital cardiac arrest system with access to high volume ECPR practitioners who can expeditiously apply ECPR, confers a 10–30% absolute survival benefit compared to continued conventional cardiopulmonary resuscitation, with neurologically favorable survival reaching 43–49% in a randomized population 1. Yannopoulos D. Bartos J. Raveendran G. Walser E. Connett J. Murray T.A. et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. The Lancet. 2020; Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar , 2. Belohlavek J. Smalcova J. Rob D. Franek O. Smid O. Pokorna M. et al. Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2022; 327: 737-747 Crossref PubMed Scopus (30) Google Scholar . The international Extracorporeal Life Support Organization (ELSO) shows ECPR survival at 30% across the world, with select high performing centers having ∼40% survival 3. Tonna J. Selzman C. Bartos J. Presson A. Ou Z. Jo Y. et al. The association of modifiable postresuscitation management across hospitals and annual case volume with survival after extracorporeal cardiopulmonary resuscitation. Critical Care Explorations. 2022; (in press) Crossref Google Scholar , though among mixed in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) populations. While for patients with initial shockable rhythms who receive immediate optimal advanced life support including defibrillation, survival can even exceed 50% 4. Bhandari S. Doan J. Blackwood J. Coult J. Kudenchuk P. Sherman L. et al. Rhythm profiles and survival after out-of-hospital ventricular fibrillation cardiac arrest. Resuscitation. 2018; 125: 22-27 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar , for patients who fail to achieve timely ROSC and thus by definition have failed CPR/defibrillation, survival is below 10%. The data suggest that for these patients, application of ECPR more than doubles survival from 10% to 30%. Amazingly, this observed survival occurs across a diverse mix of international centers with differing case volume (some with fewer than 6 cases per year 3. Tonna J. 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