Refractory Cardiac Arrest Research Articles

Abstract 4137248: Mechanical chest compression increases intrathoracic bleeding complication in patients receiving extracorporeal cardiopulmonary resuscitation

Background: Mechanical cardiopulmonary resuscitation (CPR) is widely used to ensure high-quality CPR while reducing the burden on the medical team; however, it carries the risk of intrathoracic bleeding complications. Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest also poses significant challenges due to major bleeding complications. To date, no studies have specifically investigated bleeding complications when mechanical CPR is combined with ECPR. Aim: To compare the risk of major intrathoracic bleeding between manual and mechanical CPR in ECPR patients. Methods: We retrospectively analyzed 85 patients (mean age 59.6 ± 13.3 years, 90.6% male) who underwent ECPR at our hospital between April 2017 and March 2024 after failure to achieve a return of spontaneous circulation for more than 15 minutes despite appropriate CPR. From April 2020 to June 2023, our emergency department actively used mechanical CPR devices. Patients were divided into manual and mechanical CPR groups. The primary outcome was major intrathoracic bleeding requiring transcatheter arterial embolization (TAE), and the association between mechanical CPR and the outcome was examined. Results: There were 40 patients in the manual CPR group and 45 in the mechanical CPR group. Age, sex, medical history, acute coronary syndrome, out-of-hospital cardiac arrest, presence of bystander CPR, initial rhythm, total cardiac arrest time, and CPR time did not differ between the two groups. Only BSA showed a significant difference (1.75 ± 0.17 vs 1.84 ± 0.17m 2 , p = 0.018). The primary outcome occurred in 1 case (2.5%) in the manual CPR group and 9 cases (20%) in the mechanical CPR group. Univariate analysis using Firth's penalized logistic regression showed that age, thoracic transverse diameter, and mechanical CPR were significantly associated with the primary outcome. After multivariate adjustment, the associations between the primary outcome and age (HR 1.09 [1.02-1.20], p = 0.013), mechanical CPR (HR 6.62 [1.25-68.60], p = 0.024), and the outcome remained significant. Conclusions: In ECPR patients, mechanical CPR is significantly associated with an increased risk of major intrathoracic bleeding requiring TAE compared to manual CPR.

Abstract 4135215: Eosinophilic Coronary Periarteritis (ECPA): An Under-recognized Coronary Disease with Fatal Consequences

Clinical presentation: A 50-year-old male with a paraesophageal hernia and grade D esophagitis presented to the ER with complaints of heartburn. He subsequently went into cardiac arrest and was diagnosed with a hemopericardium with tamponade physiology from a ruptured right coronary artery (RCA). Imaging Findings: Initial CT of the chest found a 1.5x1.5 cm dilation of the proximal RCA (Fig1A). Post cardiac arrest, repeat CT of the chest revealed an interval increase of the proximal RCA measuring 3.5x3.5 cm and a moderate-to-large hemopericardium (Fig1B). An emergent limited TEE demonstrated a large circumferential hemopericardium and biventricular standstill. Decision-making: In the ER, the initial symptoms resolved and he remained under observation. Hours later, he became bradycardic with a heart in the 20s and was found unresponsive. ACLS was activated and the patient was emergently cannulated and ECMO was initiated due to refractory cardiac arrest. Despite efforts from a multidisciplinary team including cardiology, cardiothoracic surgery and cardiac critical care, ROSC could not be achieved thus portending a poor prognosis. The family decided to withdraw care and the patient expired. Autopsy revealed a 925 mL hemopericardium from a ruptured 3.5 cm severely aneurysmal RCA and other remarkable findings included a 2 cm proximal aneurysm of left anterior descending artery and a 1 cm proximal aneurysm of left circumflex artery (Fig2A,B). Genetic testing for connective tissue disease was negative. Histopathology showed an eosinophilic predominant inflammatory infiltrate of the adventitia suggesting periarteritis (Fig2C) without signs of vasculitis in other organs. Conclusion: ECPA (eosinophilic coronary periarteritis) is a fatal entity with reported cases of sudden cardiac death and findings of vessel medial degeneration and coronary dissection. This case raises awareness of an under-recognized condition with limited guidance in diagnostic and therapeutic interventions.

Signs of life as a favorable predictor for non-shockable cardiac arrest undergoing extracorporeal cardiopulmonary resuscitation post non-shockable cardiac arrest

BackgroundWhen the initial rhythm of cardiac arrest is non-shockable, resuscitation outcomes tend to be unfavorable. However, signs of life (gasping, pupillary light reaction, or any form of body movement) have been suggested as favorable prognostic factors for patients with refractory cardiac arrest who are undergoing extracorporeal cardiopulmonary resuscitation (ECPR). This study determined whether signs of life are favorable neurological prognostic factors for patients undergoing ECPR post non-shockable cardiac arrest. Methods and resultsThis single-center retrospective study included 227 refractory out-of-hospital cardiac-arrest patients who had undergone ECPR, divided into four groups according to shockability of initial cardiac rhythms and presence of signs of life. Initial cardiac rhythms were shockable in 154 patients (67.8 %) and non-shockable in 73 (32.2). Favorable neurological outcomes were observed in 4.1 %, 48.2 %, 0.0 %, and 38.7 % of patients with shockable rhythm without signs of life, shockable rhythm with signs of life, non-shockable rhythm without signs of life, and non-shockable rhythm with signs of life, respectively, with significant differences. Multivariate logistic regression analysis showed an independent association of signs of life during resuscitation with favorable neurological outcomes. The adjusted odds ratios for patients with shockable and non-shockable rhythm with signs of life were 34.33 and 96.51, respectively, compared with those without signs of life. ConclusionsSigns of life during resuscitation were favorable prognostic factors in patients with refractory cardiac arrest and non-shockable rhythm. When these patients are considered for ECPR, the status of signs of life during resuscitation may facilitate the decision to perform ECPR.

Multi-dimensional assessment of long-term outcomes in patients treated with extracorporeal cardiopulmonary resuscitation during refractory cardiac arrest

Abstract Background Recent randomised controlled trials showed short-term survival benefits with extracorporeal cardiopulmonary resuscitation (ECPR) compared to standard cardiac arrest treatment in selected patients with refractory cardiac arrest. Only limited data exist on multi-dimensional long-term outcomes after ECPR. Purpose To investigate multi-dimensional long-term outcomes of ECPR survivors, that is general health status, as well as cardiac, cognitive and psychological functions. Methods This is a multicenter, mixed-method clinical study conducted by cardiologists, neurologists and psychologists between May 2021 and December 2023. Adult patients who survived ECPR with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or "ECMELLA" (i.e., VA-ECMO plus percutaneous left-ventricular assist device) in two German tertiary care centers were included. A comprehensive set of functional outcomes across multiple dimensions were assessed at approximately 18 months after the index cardiac arrest event (see Figure for stations A to E and explanation of abbreviations). Results Long-term outcomes were assessed in 32 ECPR survivors, out of whom 15 patients (46%) had received VA-ECMO and 18 (54%) ECMELLA treatment. 23 patients (70%) were male and the average age was 55 years (±13). Vital signs and laboratory markers were unremarkable. Most patients denied heart failure symptoms although the average EQ-5D-5L score was 52 (±8). The left-ventricular ejection fraction was 51% (±9), which improved by 14% (±11) in the ECMO group and 31% (±15) in the ECMELLA group since the index cardiac arrest event. Bicycle exercise (on average 6 minutes duration with a power of up to 100 Watts) and 6-minute walk test (average distance of 394 meters ±145) revealed physical impairments. 29 patients (88%) had a good cerebral performance (i.e., Cerebral Performance Category scale of 1) and the average mental status was good (mini–mental state examination score 29 ±1). 22 patients (56%) perceived (partial) impairments in activities of daily living although the average Barthel index was 100 (±5) and modified Rankin scale was 1 (±1). 12 patients (36%) were unable to return to their jobs. Remarkably, 17 (51%) and 4 (12%) patients reported depressive symptoms and suicidal thoughts, respectively. Conclusion Although ECPR remains a highly complex procedure, cardiac and neurologic functions in survivors have almost recovered, while physical and psychological impairments still persisted at 18 months after cardiac arrest. Physical rehabilitation and psychological care appear to be important measures for ECPR survivors.

Impact of extracorporeal cardiopulmonary resuscitation with ECPELLA on improvement of short-term survival in patients with refractory cardiac arrest

Abstract Background Extracorporeal cardiopulmonary resuscitation (E-CPR) is considered for cardiac arrest (CA) patients when conventional CPR is ineffective. While veno-arterial extracorporeal membrane oxygenation (VA-ECMO) robustly maintains systemic perfusion, it also increases left ventricular (LV) afterload. Recently, the transcatheter LV assist device Impella has been introduced, and the potential benefits of its combined use with VA-ECMO (ECPELLA) are anticipated. However, the utility and effective management of ECPELLA remain unclear. Purpose This single-site cohort study aimed to assess the impact of ECPELLA compared to VA-ECMO with or without intra-aortic balloon pump (IABP) in patients with refractory CA who received E-CPR. Methods We retrospectively reviewed 207 consecutive patients who underwent E-CPR between January 2012 and September 2023 at our institute. The patients were divided into two groups, ECEPLLA (n = 65) and VA-ECMO with or without IABP (n = 141). A propensity score analysis was conducted, utilizing 1:1 score matching based on variables including age, the rate of male gender, acute coronary syndrome, out-of-hospital CA (OHCA), in-hospital CA, shockable rhythm, and the time from collapse to VA-ECMO initiation, known as low flow time (LFT). We evaluated 180-day survival rates, hemodynamic data, and safety profiles. Result After propensity score matching, 57 ECPELLA patients and 57 VA-ECMO patients were included for analysis. No significant differences in the adjusted factors and comorbidities were found between the two groups. In the VA-ECMO group, 42 patients (74%) received concomitant use of IABP. During the first 72 hours following the initiation of VA-ECMO, the ECPELLA group received significantly higher total mechanical circulatory support flow compared to the VA-ECMO group, correspondingly received less catecholamine administration, and had more patients started on vasodilators and cardioprotective medications. There were no statistical differences in safety profiles, except for hemolysis and embolic cerebral infarction, between the two groups. Kaplan-Meier analysis demonstrated that the 180-day survival rates were significantly higher in the ECPELLA group than in the VA-ECMO group. In a multivariate Cox proportional hazard analysis that included age, shockable rhythm, OHCA, initial lactate levels, LFT, and ECPELLA, it was found that age (hazard ratio [HR], 1.28 [for 10-year increase]; 95% confidence interval [CI], 1.09–1.51; p = 0.002), initial lactate level (HR, 1.06; 95% CI, 1.01-1.11; p = 0.04), and ECPELLA (HR, 0.55; 95% CI, 0.36–0.85; p = 0.007) were significantly associated with 180-day mortality. Conclusion ECPELLA was associated with improvement of 180-day mortality in patient who received E-CPR. The results suggest that not only the choice of ECPELLA but also sufficient circulatory support during the acute phase, along with modulating catecholamines and vasodilators, may have influenced the prognosis.

Vascular complications in patients with peripheral veno-arterial extracorporeal membrane oxygenation: clinical-echocardiographic characteristics and predictors

Abstract Introduction Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest (CA) refractory to standard therapies. Lower limb ischemia associated with peripheral VA ECMO is frequent, and is considered a serious complication with a significant impact on the morbidity and mortality. Purpose The aim of this study was to describe the clinical-echographic parameters and analyze predictors related to vascular complications in patients with peripheral VA ECMO. Methods The study was a single-center cohort analysis. It included all consecutive adult patients with peripheral femoro-femoral VA ECMO due to refractory cardiogenic shock (CS) or cardiac arrest (CA) between March 2014 and December 2022. Patients with central cannulation were excluded. The primary endpoint was evidence of vascular complications resulting in surgical intervention. A multivariate logistic regression model was used to adjust for variables of interest. Results The study included 83 patients (65± 12 years, 54% male). The main previous diagnosis was necrotic ischemic cardiomyopathy (33%), and the most frequent indication was postcardiotomy (40.9%), mainly in SCAI D (85.5%). Cardiopulmonary resuscitation was performed in 18.1%. Femoro-femoral cannulation was percutaneuos in 95.2%. Most patients had intra-aortic balloon pump (87.1%) and distal percutaneous cannula (88.8%). A total of 18 patients presented vascular complications (21.7%): 2 patients (11.1%) amputation, 5 patients (27.7%) compartment syndrome requiring fasciotomy, 9 patients (50.0%) thrombectomy, and 2 patients (11.1%) a surgical resolution post decannulation due to AV fistula. The median duration of VA ECMO was 5 days (IQR 2-8). Among the ultrasound variables, the systolic peak velocity (SPV) in the distal territory (tibioperoneal segment) had a median of 22 cm/sec (IQR 10-30). Pulsatile spectral Doppler flow in the cannulated limb was evidenced in 42 patients (50.6%) of total population, and only in 3 patients (16.6%) with vascular complications. The survival rate from VA ECMO was 57.8%, and the survival rate to discharge 42.1%. In-hospital mortality of patients with or without vascular complications did not show statistically significant differences (54.2 % vs 58.2 %, p= 0.26). After multivariate analysis, distal territory SPV less than 20 cm/sec (OR: 2.1, 95%CI: 1.3 – 12.1, p: 0.03), as well as history of previous vascular disease, were associated with a higher number of vascular complications (OR: 2.5, 95% CI: 1.5 – 10.1, P; 0.02). Conclusions Vascular complications in patients with femoro-femoral VA ECMO remain frequent and constitute an important cause of morbidity. Decreased peak systolic velocities in the cannulated tibio-peroneal territory, as well as a history of previous vascular disease were significantly associated with a higher rate of vascular complications.

Echocardiographic evaluation of ventricular performance in VA-ECMO weaning: results from a observational monocentric prospective study

Abstract Background Although temporary mechanical circulatory support (MCS) devices are increasingly used in the management of cardiogenic shock (CS), several open question regarding the kind of support and timing of institution/weaning remains open. Echocardiography is widely applied to drive the weaning process and decision although there are no standardized protocols for the trial nor accordance on the parameters to apply. Purpose We sought to evaluate the overall accuracy of echocardiographic indices in predicting successful weaning from VA ECMO in patients with CS. Specifically, we tested total isovolumic time (tIVT), an index of ventricular performance, and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Monocentric prospective study on adults receiving VA-ECMO due to refractory CS and/or cardiac arrest (CA) from 2012 to 2020. Echocardiography was performed at VA-ECMO placement and during the weaning trials. Weaning trials were performed daily, starting 48 hours after VA-ECMO institution, when patients were hemodynamically stable: mean arterial pressure >65 mmHg, no or minimum adrenergic support (vasoactive inotropic score <10), heart rate <110 bpm, lactate <2 mmol/L, and no signs of respiratory distress. Weaning trials were performed with a stepwise decrease of VA-ECMO blood flow until reaching 1 or 1.5 L/min under adequate anticoagulation. Successful weaning was defined as removal of VA-ECMO with no requirement for further MCS in the following 30 days. Results 76 patients were enrolled (23.8% female, 54.2±10.6 years-old), 52.6% due to CA. Median duration of VA-ECMO was 58 hours; 47 (61.8%) had intra-aortic balloon pump (IABP) inserted upfront. In-hospital mortality was 62.4% overall, 40% for CS without CA. 6 of the 32 weaned patients died for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (table): stroke volume >13.9 mL (p 0.002), tIVT >23.6 min/sec (p 0.053), LV VTI >6.6 cm (p<0.001), MAPSE >6.15 mm (p 0.001), TAPSE >11 mm (p 0.023), RV S’ >10 cm/s (p 0.012). LVEF did not reach the statistical significance. Figure shows Kaplan-Meier analysis on echocardiographic indices collected at time of cannulation (panel A) and during the last weaning trial (panel B). Conclusions Echocardiography is pivotal in defining cardiac recovery and monitoring the weaning trial. Indices reflecting ventricular performance and delivered flow from LV were associated with weaning success both at VA-ECMO institution and throughout the weaning trials. Considering the known limitations of LVEF (heart rate, loading and left ventricular dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation of patients in the acute setting.TableFigure

Higher blood glucose within the first 72 hours after prolonged cardiac arrest predict poor prognosis: a post-hoc analysis of Prague OHCA trial

Abstract Background and purpose Both low and higher glucose levels and their tight control were associated with worse prognosis of critically ill patients. We performed a post-hoc analysis of treated Prague OHCA trial population of patients subjected to extracorporeal cardiopulmonary resuscitation (ECPR) vs. standard approach for refractory cardiac arrest, aimed to assess relationship of glucose levels in the first 72 hours after admission to the neurological outcome. Methods Prague OHCA trial enrolled adults with a witnessed refractory OHCA of presumed cardiac origin. In this post-hoc analysis, the effects blood glucose on the best cerebral performance category (CPC) within 180 days was examined. Blood samples for glycemia evaluation were drawn at admission and then every 3 hours within the first 3 days. Fischer exact test was used to analyze the impact on the prognosis (CPC 1-2 = good and CPC 3-5 = poor prognosis). Results Patients with CPC 1-2 did not differ in blood glucose on admission from patients with CPC 3-5. However, patients with type 2 diabetes mellitus had significantly worse prognosis (83 vs. 60% of diabetics vs. non-diabetics had poor prognosis, p = 0.007). Glycemia on admission was slightly but significantly related to the amount of given epinephrine and to the serum triglycerides. Patients having at least 3 glucose levels >10 mmol/L within the first 72 hours had worse neurological prognosis: CPC 1-2 was reached in 61.4% of patients with less than 3 levels >10 mmol/L, but only in 24% of patients that fulfilled this criterion (p=0.000004). Conclusions Repeatedly higher blood glucose within the first 72 hours after admission for prolonged cardiac arrest are related to worse prognosis.

ECPR-the evolving role in cardiac arrest.

Extracorporeal cardiopulmonary resuscitation (ECPR) describes the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) to restore blood circulation in patients during refractory cardiac arrest. So far, ECPR is not the standard of care but has become part of clinical routine for select patients in many places. As ECPR is ahighly invasive support option associated with considerable risks for fatal complications, premature use in patients who may have return of spontaneous circulation should be avoided. However, the selection criteria for ECPR are still evolving, as the search for evidence is ongoing. Recent randomized controlled trials of different ECPR strategies support its use within integrated systems built around highly specialized ECPR centers. The ECPR caseload is an important predictor of patient survival, and continuous training is key for evidence-based quality of care. Typical complications after ECPR include vascular injury or malposition of cannulas, thrombotic complications, hemolysis, and bleeding events that require early detection and interdisciplinary management. When provided by highly specialized and well-trained expert teams in dedicated ECPR centers within integrated pre-hospital and intra-hospital emergency care systems, ECPR may improve survival in select patients with refractory cardiac arrest. This article is freely available.

Hybrid Surgical treatment of thoraco-abdominal aneurysm: case report

The conventional surgical treatment of TAAA is complex and is associated with important perioperative mortality and mobidity. There is consensus that endovascular aneurysm repair (EVAR) is the preferred treatment for high-risk patients, but the availability of endovascular-branched grafts are quite limited. As an alternative for such dilema, the hybrid approach came as another possibility for high risk patients where totally endovascular treatment is not feasible and clinical condition for convencional surgery is prohibitive. Thus, the objective of this study is to report our service's experience with the hybrid surgical technique for treatment of this severe condition. Male patient, 73 years old, diagnosed with fusiform aortic aneurysm at the thoracoabdominal transition level, measuring 10.1 x 8.9 cm, associated with a large retroperitoneal hematoma, likely corresponding to an aneurysm rupture. The hybrid strategy was chosen, involving two stages: conventional surgery and endovascular procedures. However, approximately 24 hours after the first surgery the patient had refractory cardiac arrest at intensive care unit. Surgical treatment of thoracoabdominal aneurysm is a complex issue, and the trend over time is tending toward total endovascular treatment, and these devices will undoubtedly evolve and be used more and more in the years to come. However, the hybrid repair will likely remain a standard procedure for a while, until total endovascular procedures become more common and the necessary endovascular materials widely available.

Age as a Mortality Predictor in ECPR Patients.

Extracorporeal cardiopulmonary resuscitation (ECPR) is an advanced technique using extracorporeal membrane oxygenation (ECMO) to support patients with refractory cardiac arrest. Age significantly influences ECPR outcomes, with younger patients generally experiencing better survival and neurological outcomes due to many aspects. This review explores the impact of age on ECPR effectiveness, emphasizing the need to consider age alongside other clinical factors in patient selection. Survival rates differ notably between in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA), highlighting the importance of rapid intervention. The potential of artificial intelligence to develop predictive models for ECPR outcomes is discussed, aiming to improve decision-making. Ethical considerations around age-based treatment decisions are also addressed. This review advocates for a balanced approach to ECPR, integrating clinical and ethical perspectives to optimize patient outcomes across all age groups.

Impact of routine extracorporeal cardiopulmonary resuscitation service on the availability of donor organs

In refractory cardiac arrest, extracorporeal cardiopulmonary resuscitation may increase the survival chance. However, in cases of unsuccessful treatment, extracorporeal cardiopulmonary resuscitation may additionally provide an important source of organ donors. Therefore, we hypothesized that implementing extracorporeal cardiopulmonary resuscitation service into a high-volume cardiac arrest center's routine would increases organ donors' availability. MethodsOur retrospective observational study analyzed out-of-hospital cardiac arrest patients admitted to the General University Hospital in Prague between 2007 and 2020.The following groups were analyzed regarding the recruitment of donors: before and after extracorporeal cardiopulmonary resuscitation implementation. We assessed the number of donors referred, the number of organs harvested, and the organ's survival. ResultsWe analyzed the results of 1158 patients after out-of-hospital cardiac arrest. In the conventional approach period, 11 donors were referred, of which seven were accepted. During the extracorporeal cardiopulmonary resuscitation period, the number of donors increased to 80, of whom 42 were accepted. The number of donated organs was 18 and 119 in the respective periods, corresponding to 3.6 vs. 13.2 (p = 0.033) harvested organs per year. One-year survival of transplanted organs was 94.4% vs. 99.2%, and five-year survival was 94.4% vs. 95.9% in relevant periods. Conventional and extracorporeal cardiopulmonary resuscitation did not affect donor organ survival. ConclusionEstablishing a high-volume cardiac arrest centre providing an extracorporeal cardiopulmonary resuscitation service may increase not only the number of prolonged cardiac arrest survivors but also the number of organ donors. In addition, the performances of donated organs were high and comparable between both treatment methods.

Extracorporeal Membrane Oxygenation Pathway for Management of Refractory Cardiac Arrest: a Retrospective Study From a National Center of Extracorporeal Cardiopulmonary Resuscitation.

Cardiac arrest remains a critical condition with high mortality and catastrophic neurological impact. Extracorporeal cardiopulmonary resuscitation (ECPR) has been introduced as an adjunct in cardiopulmonary resuscitation modalities. However, survival with good neurological outcomes remains a major concern. This study aims to explore our early experience with ECPR and identify the factors associated with survival in patients presenting with refractory cardiac arrest. This is a retrospective cohort study analyzing 6-year data from a tertiary center, the country reference for ECPR. This study was conducted at a national center of ECPR. Participants of this study were adult patients who experienced witnessed refractory cardiopulmonary arrest and were supported by ECPR. ECPR was performed for eligible patients as per the local service protocols. Data from 87 patients were analyzed; of this cohort, 62/87 patients presented with in-hospital cardiac arrest (IHCA) and 25/87 presented with out-of-hospital cardiac arrest (OHCA). Overall survival to decannulation and hospital discharge rates were 26.4% and 25.3%, respectively. Among survivors (n = 22), 19 presented with IHCA (30.6%), while only 3 survivors presented with OHCA (12%). A total of 15/87 (17%) patients were alive at 6-month follow-up. All survivors had good neurological function assessed as Cerebral Performance Category 1 or 2. Multivariate logistic regression to predict survival to hospital discharge showed that IHCA was the only independent predictor (odds ratio: 5.8, P = 0.042); however, this positive association disappeared after adjusting for the first left ventricular ejection fraction after resuscitation. In this study, the use of ECPR for IHCA was associated with a higher survival to discharge compared to OHCA. This study demonstrated a comparable survival rate to other established centers, particularly for IHCA. Neurological outcomes were comparable in both IHCA and OHCA survivors. However, large multicenter studies are warranted for better understanding and improving the outcomes.

Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation

PurposePatients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) frequently develop arterial hyperoxaemia, which may be harmful. However, lower oxygen saturation targets may also lead to harmful episodes of hypoxaemia.MethodsIn this registry-embedded, multicentre trial, we randomly assigned adult patients receiving VA-ECMO in an intensive care unit (ICU) to either a conservative (target SaO2 92–96%) or to a liberal oxygen strategy (target SaO2 97–100%) through controlled oxygen administration via the ventilator and ECMO gas blender. The primary outcome was the number of ICU-free days to day 28. Secondary outcomes included ICU-free days to day 60, mortality, ECMO and ventilation duration, ICU and hospital lengths of stay, and functional outcomes at 6 months.ResultsFrom September 2019 through June 2023, 934 patients who received VA-ECMO were reported to the EXCEL registry, of whom 300 (192 cardiogenic shock, 108 refractory cardiac arrest) were recruited. We randomised 149 to a conservative and 151 to a liberal oxygen strategy. The median number of ICU-free days to day 28 was similar in both groups (conservative: 0 days [interquartile range (IQR) 0–13.7] versus liberal: 0 days [IQR 0–13.7], median treatment effect: 0 days [95% confidence interval (CI) – 3.1 to 3.1]). Mortality at day 28 (59/159 [39.6%] vs 59/151 [39.1%]) and at day 60 (64/149 [43%] vs 62/151 [41.1%] were similar in conservative and liberal groups, as were all other secondary outcomes and adverse events. The conservative group experienced 44 (29.5%) major protocol deviations compared to 2 (1.3%) in the liberal oxygen group (P < 0.001).ConclusionsIn adults receiving VA-ECMO in ICU, a conservative compared to a liberal oxygen strategy, did not affect the number of ICU-free days to day 28.

Impact of extracorporeal cardiopulmonary resuscitation on neurological prognosis and survival in adult patients after cardiac arrest: An individual pooled patient data meta-analysis

BackgroundWe aimed to estimate the effect of extracorporeal cardiopulmonary resuscitation (ECPR) on neurological outcome and mortality, when compared to conventional cardiopulmonary resuscitation (CCPR), using an individual patient data meta-analysis (IPDMA). MethodsA systematic literature search was performed up to the 20th of October 2022 in the PubMed, EMBASE and CENTRAL databases. For observational studies with unmatched populations, a propensity score including age, location of arrest and initial rhythm was used to match ECPR and CCPR patients in a 1:1 ratio. The primary and secondary outcomes were unfavorable neurological outcome (Cerebral Performance Category of 3–5) and mortality, respectively, which were both collected at different time-points. ResultsData from 17 studies, including 2064 matched cardiac arrest (CA) patients (1031 ECPR and 1033 CCPR cases) were included. In comparison to CCPR, ECPR was associated with a decreased odds of unfavorable neurological outcome (847, 82.2% vs. 897, 86.8% − OR 0.68 [95%CI 0.53–0.87]; p = 0.002) and death (803, 77.9% vs. 860, 83.3% − OR 0.68 [95%CI 0.54–0.86]; p = 0.001). These results were consistent across most of the prespecified subgroups. Moreover, the odds of both unfavorable neurological outcome and mortality were significantly influenced by initial rhythm, cause of arrest and combinations of lactate levels on admission and duration of resuscitation. ConclusionsThis IPDMA showed that ECPR was associated with significantly lower rates of unfavorable neurological outcome and mortality in refractory CA. The overall effect could be influenced by CA characteristics and the severity of the initial injury.

Successful Extracorporeal Cardiopulmonary Resuscitation Despite Aortic Occlusion.

We present the case of a 62-year-old man with severe coronary artery disease who presented to the hospital in refractory ventricular fibrillation cardiac arrest. He showed signs of life despite prolonged resuscitation. We thus decided to initiate extracorporeal cardiopulmonary resuscitation (ECPR). The patient had a known total occlusion of his infrarenal aorta that had been surgically bypassed with a bifemoral-axillary graft. We successfully initiated ECPR via the surgical graft, establishing blood flow to the central circulation through the axillary artery in a peripheral configuration while ensuring blood flow to the left leg via the femoral-femoral graft. The patient was extubated neurologically intact the following day and subsequently underwent coronary artery bypass graft surgery while on extracorporeal membrane oxygenation (ECMO) support. He was subsequently weaned off inotropic support and decannulated from ECMO. He was discharged home neurologically intact and independent in his activities of daily living. This case demonstrates that cannulation for ECPR via a surgical vascular graft is possible and that a total occlusion of the infrarenal aorta in the presence of a surgical bypass is not an absolute contraindication to ECMO.

Acute kidney injury as a prognostic predictor of in-hospital mortality and neurological outcomes in patients after extracorporeal cardiopulmonary resuscitation.

Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly being applied to patients with refractory cardiac arrest, but the survival rate to hospital discharge is only approximately 29%. Because ECPR requires intensive resources, it is important to predict outcomes. We therefore investigated the prognostic association between acute kidney injury (AKI) and ECPR to confirm the performance of AKI as a prognostic predictor of in-hospital mortality and neurological outcomes in ECPR. We conducted a retrospective observational study on patients undergoing ECPR for cardiac etiology at Chonnam National University Hospital from 2015 to 2021. The group diagnosed with AKI in any KDIGO category within the first 48 h after ECPR was compared to that without AKI, and the primary outcome of the study was in-hospital mortality. Of 138 enrolled patients, 83 were studied. Hospital mortality occurred in 49 patients (59%), and 55 (66.3%) showed poor neurological outcomes. The AKI group displayed significantly elevated in-hospital mortality (77.8% vs 24.1%) and poor neurological outcomes (81.5% vs 37.9%) compared to the non-AKI group (p < 0.001). Regression analysis showed that AKI was associated with significantly higher rates of both in-hospital mortality (odds ratio (OR) range 10.75-12.88) and neurologic outcomes (OR range 5.9-6.22). There was a significant association of AKI with both in-hospital mortality and poor neurologic outcome in patients after ECPR, and AKI can be used as an early prognostic predictor in these patients.

Extracorporeal Cardiopulmonary Resuscitation: CME Review.

Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly being used for refractory cardiac arrest for both in-hospital and out-of-hospital cardiac arrests. The term eCPR refers to cannulating a patient to an extracorporeal membrane oxygenation (ECMO) circuit to provide perfusion after cardiac arrest refractory to standard cardiopulmonary resuscitation. Extracorporeal cardiopulmonary resuscitation has been shown to offer increased survival benefit among a select group of adult and pediatric patients experiencing refractory cardiac arrests, both in hospital and out of hospital. Extracorporeal cardiopulmonary resuscitation should be considered when (1) the cardiac arrest is witnessed, (2) the patient receives high-quality cardiopulmonary resuscitation, (3) the patient is at or in close proximity to an ECMO center, (4) there is a reversible cause for the cardiac arrest where the perfusion from the ECMO circuit serves as a bridge to recovery, and (5) the treating facility has a robust multidisciplinary system in place to facilitate rapidly moving patients from site of arrest to site of cannulation to intensive care unit. To develop an eCPR system of care, a multidisciplinary team consisting of prehospital, emergency medicine, in-hospital, proceduralist, perfusionist, and intensive care medical professionals must be established who support the use of eCPR for refractory cardiac arrest. The future of eCPR is the development of systems of care that use eCPR for a narrow subset of pediatric out-of-hospital cardiac arrests.

Emergent coronary revascularization with percutaneous coronary intervention and coronary artery bypass grafting in patients receiving extracorporeal cardiopulmonary resuscitation.

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue for refractory cardiac arrest, of which acute coronary syndrome is a common cause. Data on the coronary revascularization strategy in patients receiving ECPR remain limited. The ECPR databases from two referral hospitals were screened for patients who underwent emergent revascularization. The baseline characteristics were matched 1:1 using propensity score between patients who underwent coronary artery bypass grafting (CABG) and those who received percutaneous coronary intervention (PCI). Outcomes, including success rate of weaning from extracorporeal membrane oxygenation (ECMO), hospital survival, and midterm survival in hospital survivors, were compared between CABG and PCI. After matching, most of the patients (95%) had triple vessel disease. Compared with PCI (n = 40), emergent CABG (n = 40) had better early outcomes, in terms of the rates of successful ECMO weaning (71.1% vs 48.7%, P = 0.05) and hospital survival (56.4% versus 32.4%, P = 0.04). After a mean follow-up of 2 years, both revascularization strategies were associated with favourable midterm survival among hospital survivors (75.3% after CABG vs 88.9% after PCI, P = 0.49), with a trend towards fewer reinterventions in patients who underwent CABG (P = 0.07). In patients who received ECPR because of triple vessel disease, the hospital outcomes were better after emergent CABG than after PCI. More evidence is required to determine the optimal revascularization strategy for patients who receive ECPR.

Association of hyperfibrinolysis with poor prognosis in refractory circulatory arrest: implications for extracorporeal cardiopulmonary resuscitation

BackgroundIdentifying candidates for extracorporeal cardiopulmonary resuscitation (eCPR) is challenging, and novel predictive markers are urgently needed. Hyperfibrinolysis is linked to tissue hypoxia and is associated with poor outcomes in out-of-hospital cardiac arrest (OHCA). Rotational thromboelastometry (ROTEM) can detect or rule out hyperfibrinolysis, and could, therefore, provide decision support for initiation of eCPR. We explored early detection of hyperfibrinolysis in patients with refractory OHCA referred for eCPR. MethodsWe analysed ROTEM results and resuscitation parameters of 57 adult patients with ongoing OHCA who presented to our ICU for eCPR evaluation. ResultsHyperfibrinolysis, defined as maximum lysis ≥15%, was present in 36 patients (63%) and was associated with higher serum lactate, lower arterial blood pH, and increased low-flow intervals. Of 42 patients who achieved return of circulation, 28 had a poor 30-day outcome. The incidence of hyperfibrinolysis was higher in the poor outcome group compared with patients with good outcomes (75% [21 of 28] vs 7.1% [1 of 14]; P<0.001). The ratio of EXTEM A5 to lactate concentration showed good predictive value in detecting hyperfibrinolysis (AUC of 0.89 [95% confidence interval 0.8–1]). ConclusionsHyperfibrinolysis was common in patients with refractory cardiac arrest, and was associated with poor prognosis. The combination of high lactate with early clot firmness values, such as EXTEM A5, appears promising for early detection of hyperfibrinolysis. This finding could facilitate decisions to perform eCPR, particularly for patients with prolonged low-flow duration but lacking hyperfibrinolysis.