Extracorporeal cardiopulmonary resuscitation for refractory out‐of‐hospital cardiac arrest: Lessons learned from recent clinical trials

Cardiac arrest is a leading contributor to morbidity and mortality in the United States. Survival has been historically dependent on high‐quality cardiopulmonary resuscitation (CPR) and rapid defibrillation. However, a large percentage of patients remain in refractory cardiac arrest despite adherence to structured advanced cardiac life support algorithms in which these factors are emphasized. Veno‐arterial extracorporeal membrane oxygenation is becoming an increasingly used rescue therapy for patients in refractory cardiac arrest to restore oxygen delivery by extracorporeal CPR (ECPR). Recently published clinical trials have provided new insights into ECPR for patients who sustain an outside hospital cardiac arrest (OHCA). In this narrative review, we summarize the rationale for, results of, and remaining questions from these recently published clinical trials. The existing observational data combined with the latest clinical trials suggest ECPR improves mortality in patients in refractory arrest. However, a mixed methods trial is essential to understand the complexity, context, and effectiveness of implementing an ECPR program.

[1]  I. V. D. van der Horst,et al.  Early Extracorporeal CPR For Refractory Out-of-Hospital Cardiac Arrest - a pre-planned per-protocol analysis OF THE INCEPTION-TRIAL. , 2023, Resuscitation.

[2]  Arman Shafiee,et al.  Extracorporeal cardiopulmonary resuscitation for out‐of‐hospital cardiac arrest: A meta‐analysis of randomized controlled trials , 2023, Pacing and clinical electrophysiology : PACE.

[3]  R. Neumar,et al.  Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation , 2023, Circulation.

[4]  A. Komárek,et al.  Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Invasive Treatment: a post-hoc Bayesian re-analysis of a randomized clinical trial. , 2023, Chest.

[5]  C. Brízido,et al.  Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: a systematic review and meta-analysis of randomized clinical trials , 2023, Internal and Emergency Medicine.

[6]  I. Elgendy,et al.  Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest: A Meta-Analysis of Randomized Trials. , 2023, JACC: Cardiovascular Interventions.

[7]  T. Aufderheide,et al.  Intraarrest transport, extracorporeal cardiopulmonary resuscitation, and early invasive management in refractory out-of-hospital cardiac arrest: an individual patient data pooled analysis of two randomised trials , 2023, EClinicalMedicine.

[8]  A. Zangrillo,et al.  Refractory out-of-hospital cardiac arrest and extracorporeal cardiopulmonary resuscitation: A meta-analysis of randomized trials. , 2023, Artificial organs.

[9]  J. Maessen,et al.  Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. , 2023, The New England journal of medicine.

[10]  M. Gausche-Hill,et al.  Implementation of a Regional Extracorporeal Membrane Oxygenation Program for Refractory Ventricular Fibrillation Out-of-Hospital Cardiac Arrest. , 2023, Resuscitation.

[11]  M. Huptych,et al.  Extracorporeal versus conventional cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: a secondary analysis of the Prague OHCA trial , 2022, Critical Care.

[12]  T. Henry,et al.  Eligibility of Out-of-Hospital Cardiac Arrest Patients for Extracorporeal Cardiopulmonary Resuscitation in the United States: A Geographic Information System Model. , 2022, Resuscitation.

[13]  J. Tonna,et al.  ECPR may be the most effective intervention for refractory cardiac arrest-ever. , 2022, Resuscitation.

[14]  R. Thiagarajan,et al.  The Association of Modifiable Postresuscitation Management and Annual Case Volume With Survival After Extracorporeal Cardiopulmonary Resuscitation , 2022, Critical care explorations.

[15]  B. McNally,et al.  Variation in Out-of-Hospital Cardiac Arrest Survival Across Emergency Medical Service Agencies , 2022, Circulation. Cardiovascular quality and outcomes.

[16]  A. Zangrillo,et al.  Extracorporeal cardiopulmonary resuscitation for out‐of‐hospital cardiac arrest: A systematic review and meta‐analysis of randomized and propensity score‐matched studies , 2022, Artificial organs.

[17]  M. Huptych,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. , 2022, JAMA.

[18]  A. Watson,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 , 2021, Journal of Emergency Medicine.

[19]  J. Soar,et al.  European Resuscitation Council Guidelines 2021: Adult advanced life support. , 2021, Resuscitation.

[20]  R. Neumar,et al.  Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest (EROCA): Results of a Randomized Feasibility Trial of Expedited Out-of-Hospital Transport. , 2021, Annals of emergency medicine.

[21]  P. Kudenchuk,et al.  Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. , 2020, Circulation.

[22]  Dana M. Zive,et al.  Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. , 2020, JAMA.

[23]  R. Thiagarajan,et al.  Patient and Institutional Characteristics Influence the Decision to Use Extracorporeal Cardiopulmonary Resuscitation for In‐Hospital Cardiac Arrest , 2020, Journal of the American Heart Association.

[24]  T. Hifumi,et al.  Extracorporeal Cardiopulmonary Resuscitation for Out‐of‐Hospital Cardiac Arrest in Adult Patients , 2020, Journal of the American Heart Association.

[25]  Y. Gan,et al.  The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis , 2020, Critical Care.

[26]  F. Pappalardo,et al.  Extracorporeal membrane oxygenation for refractory cardiac arrest: a retrospective multicenter study , 2020, Intensive Care Medicine.

[27]  T. Aufderheide,et al.  Improved Survival With Extracorporeal Cardiopulmonary Resuscitation Despite Progressive Metabolic Derangement Associated With Prolonged Resuscitation , 2020, Circulation.

[28]  J. Park,et al.  Time from arrest to extracorporeal cardiopulmonary resuscitation and survival after out‐of‐hospital cardiac arrest , 2019, Emergency medicine Australasia : EMA.

[29]  M. Link,et al.  2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergenc , 2019, Circulation.

[30]  D. Benhamou,et al.  Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study. , 2019, European heart journal.

[31]  Y. Naka,et al.  Left ventricular distension and venting strategies for patients on venoarterial extracorporeal membrane oxygenation. , 2019, Journal of thoracic disease.

[32]  D. Beiser,et al.  Cost-utility of extracorporeal cardiopulmonary resuscitation in patients with cardiac arrest. , 2019, Resuscitation.

[33]  M. Schluep,et al.  One-year survival after in-hospital cardiac arrest: A systematic review and meta-analysis. , 2018, Resuscitation.

[34]  P. Chan,et al.  Long-Term Survival Trends of Medicare Patients After In-Hospital Cardiac Arrest: Insights from Get With The Guidelines-Resuscitation®. , 2018, Resuscitation.

[35]  C. Bode,et al.  Influence of low-flow time on survival after extracorporeal cardiopulmonary resuscitation (eCPR) , 2017, Critical Care.

[36]  T. Iwama,et al.  Association between delay to coronary reperfusion and outcome in patients with acute coronary syndrome undergoing extracorporeal cardiopulmonary resuscitation. , 2017, Resuscitation.

[37]  Y. Cho,et al.  Outcomes of extracorporeal life support in out-of-hospital cardiac arrest (OHCA): Patient selection is crucial. , 2016, Resuscitation.

[38]  A. Singer,et al.  Venoarterial Extracorporeal Membrane Oxygenation in Adults With Cardiac Arrest , 2016, Journal of intensive care medicine.

[39]  Dong Sun Choi,et al.  Extracorporeal life support and survival after out-of-hospital cardiac arrest in a nationwide registry: A propensity score-matched analysis. , 2016, Resuscitation.

[40]  E. Bonnefoy,et al.  Extracorporeal life support for refractory out-of-hospital cardiac arrest: Should we still fight for? A single-centre, 5-year experience. , 2016, International journal of cardiology.

[41]  C. Chiu,et al.  Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation. , 2015, Resuscitation.

[42]  M. Holzer,et al.  The incidence of "load&go" out-of-hospital cardiac arrest candidates for emergency department utilization of emergency extracorporeal life support: A one-year review. , 2015, Resuscitation.

[43]  K. Phan,et al.  Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest: a meta-analysis. , 2015, Journal of cardiothoracic and vascular anesthesia.

[44]  O. Ramilo,et al.  Abstract O.29: Transcriptional Profiling Discriminates Complete and Incomplete KD from Human Adenovirus , 2015 .

[45]  B. Hiebert,et al.  Resuscitative extracorporeal membrane oxygenation for in hospital cardiac arrest: a Canadian observational experience. , 2014, Resuscitation.

[46]  B. McNally,et al.  Recent Trends in Survival From Out-of-Hospital Cardiac Arrest in the United States , 2014, Circulation.

[47]  M. Acker,et al.  Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest. , 2014, Resuscitation.

[48]  L. Becker,et al.  Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest--a comparison with that for extracorporeal rescue for in-hospital cardiac arrest. , 2014, Resuscitation.

[49]  T. Atsumi,et al.  Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study. , 2014, Resuscitation.

[50]  R. Cheng,et al.  Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. , 2014, The Annals of thoracic surgery.

[51]  Z. Yen,et al.  An observational study of extracorporeal CPR for in-hospital cardiac arrest secondary to myocardial infarction , 2013, Emergency Medicine Journal.

[52]  J. Vincent,et al.  Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest. , 2013, Resuscitation.

[53]  T. Walther,et al.  Door-to-implantation time of extracorporeal life support systems predicts mortality in patients with out-of-hospital cardiac arrest , 2013, Clinical Research in Cardiology.

[54]  K. Maekawa,et al.  Extracorporeal Cardiopulmonary Resuscitation for Patients With Out-of-Hospital Cardiac Arrest of Cardiac Origin: A Propensity-Matched Study and Predictor Analysis* , 2013, Critical care medicine.

[55]  P. Chan,et al.  Trends in survival after in-hospital cardiac arrest. , 2013, The New England journal of medicine.

[56]  A. Agha,et al.  A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest. , 2012, Resuscitation.

[57]  Daniel Davis,et al.  Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. , 2011, The New England journal of medicine.

[58]  Comilla Sasson,et al.  Out-of-hospital cardiac arrest surveillance --- Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005--December 31, 2010. , 2011, Morbidity and mortality weekly report. Surveillance summaries.

[59]  Eun-Seok Jeon,et al.  Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation* , 2011, Critical care medicine.

[60]  M. Hazinski,et al.  Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. , 2010, Circulation.

[61]  R. Berg,et al.  Rhythms and outcomes of adult in-hospital cardiac arrest* , 2010, Critical care medicine.

[62]  N. Chi,et al.  Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation* , 2008, Critical care medicine.

[63]  N. Chi,et al.  Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis , 2008, The Lancet.

[64]  D. Stub,et al.  Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). , 2015, Resuscitation.