Experience with percutaneous venoarterial cardiopulmonary bypass for emergency circulatory support

Efficacy of portable and percutaneous cardiopulmonary bypass rewarming versus that of conventional internal rewarming for patients with accidental deep hypothermia

OBJECTIVE

Since 2001, at our institution, a portable and percutaneous cardiopulmonary bypass system has been used for rewarming of patients with accidental deep hypothermia. Before 2001, a conventional internal rewarming technique was used. The aim of this research is to examine the efficacy of portable and percutaneous cardiopulmonary bypass for rewarming of patients with accidental severe hypothermia and compare it with that of conventional rewarming methods.

DESIGN

Historical study.

SETTING

The exclusive emergency medical center and trauma center level 1 in Western Kanagawa, Japan.

PATIENTS

From April 1992 to March 2009, 70 patients with accidental deep hypothermia (core temperature <28°C) were transferred to our hospital. Two patients presented with intracranial hemorrhage on initial head computed tomography scans. These two patients were excluded because each required an emergency operation. Therefore, 68 patients were included in this study. We compared patients' clinical characteristics and outcomes. The parameters included the following: sex, age, vital signs on arrival to our hospital (Glasgow coma Scale scores, systolic blood pressure, heart rate, respiratory rate, core temperature), electrocardiogram on arrival to our hospital, rewarming speed, time of rewarming until 34°C was reached, ventricular fibrillation occurrence rate during rewarming, cause of cold environmental exposure, Glasgow Outcome Scale scores, and mortality. In addition, we divided the conventional and portable and percutaneous cardiopulmonary bypass rewarming groups into two categories depending on whether cardiopulmonary arrest occurred on arrival to our hospital. We also compared the survival rate and average Glasgow Outcome Scale scores for each group.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients' clinical backgrounds did not differ significantly between the conventional and portable and percutaneous cardiopulmonary bypass rewarming groups. Glasgow Outcome Scale scores and survival rates of the portable and percutaneous cardiopulmonary bypass rewarming group patients, irrespective of whether cardiopulmonary arrest was experienced on arrival to our hospital, were significantly higher than those of the conventional rewarming group.

CONCLUSIONS

Portable and percutaneous cardiopulmonary bypass rewarming can improve the mortality rates and Glasgow Outcome Scale scores of accidental deep hypothermia patients.

Derivation of the uncontrolled donation after circulatory determination of death protocol for New York city

Evidence from Europe suggests establishing out-of-hospital, uncontrolled donation after circulatory determination of death (UDCDD) protocols has potential to substantially increase organ availability. The study objective was to derive an out-of-hospital UDCDD protocol that would be acceptable to New York City (NYC) residents. Participatory action research and the SEED-SCALE process for social change guided protocol development in NYC from July 2007 to September 2010. A coalition of government officials, subject experts and communities necessary to achieve support was formed. Authorized NY State and NYC government officials and their legal representatives collaboratively investigated how the program could be implemented under current law and regulations. Community stakeholders (secular and religious organizations) were engaged in town hall style meetings. Ethnographic data (meeting minutes, field notes, quantitative surveys) were collected and posted in a collaborative internet environment. Data were analyzed using an iterative coding scheme to discern themes, theoretical constructs and a summary narrative to guide protocol development. A clinically appropriate, ethically sound UDCDD protocol for out-of-hospital settings has been derived. This program is likely to be accepted by NYC residents since the protocol was derived through partnership with government officials, subject experts and community participants.

Usefulness of routine laboratory parameters in the decision to treat refractory cardiac arrest with extracorporeal life support

AIM

To evaluate the usefulness of routine laboratory parameters in the decision to treat refractory cardiac arrest patients with extracorporeal life support (ECLS).

METHODS

Sixty-six adults with witnessed cardiac arrest of cardiac origin unrelated to poisoning or hypothermia undergoing cardiopulmonary resuscitation without return of spontaneous circulation (duration: 155 min [120-180], median, [25-75%-percentiles]) were included in a prospective cohort-study. ECLS was implemented under cardiac massage, using a centrifugal pump connected to a hollow-fiber membrane-oxygenator, aiming to maintain ECLS flow ≥ 2.5 l/min and mean arterial pressure ≥ 60 mm Hg.

RESULTS

Forty-seven of 66 patients died within 24 h from multiorgan failure and massive capillary leak. Of 19/66 patients who survived ≥ 24 h with stable circulatory conditions permitting neurological evaluation, four became conscious and were transferred for further cardiac assistance, while three became organ donors. Ultimately, one patient survived without neurologic sequelae after cardiac transplantation. Using multivariate analysis, only pre-cannulation peripheral venous oxygen saturation (SpvO₂, 28% [15-52]) independently predicted inability to maintain targeted ECLS conditions ≥ 24 h (odds ratio for each 10%-decrease [95%-confidence interval]: 1.65 [1.21; 2.25], p=0.002). The area under the receiver-operating-characteristics curve was 0.78 [0.63; 0.93]. SpvO₂ cut-off value of 33% was associated with a sensitivity of 0.68 [0.50; 0.83] and specificity of 0.81 [0.54; 0.96]. SpvO₂ ≤ 8%, lactate concentration ≥ 21 mmol/l, fibrinogen ≤ 0.8 g/l, and prothrombin index ≤ 11% predicted premature ECLS discontinuation with a specificity of 1.

CONCLUSION

SpvO₂ is useful to predict the inability of maintaining refractory cardiac arrest victims on ECLS without detrimental capillary leak and multiorgan failure until neurological evaluation.

Better outcome after cardiopulmonary resuscitation using percutaneous emergency circulatory support in non-coronary patients compared to those with myocardial infarction

BACKGROUND & OBJECTIVES

Mobile heart-lung-machines applied by percutaneous cannulation are mostly used in patients suffering from acute myocardial infarction (AMI). Whether patients with non-coronary reasons for circulatory arrest benefit of percutaneous emergency circulatory support (PECS) in the same way is still unclear.

METHODS

We included 22 consecutive patients who were treated by PECS during a registry period of two years. Primary study endpoint was 30-day mortality rate.

RESULTS

Circulatory arrest was caused by AMI in 14 patients (64%). The remaining 8 patients suffered from cardiomyopathy/myocarditis, 4; pulmonary embolism, 2; acute pulmonary failure, 1; and tumor lysis syndrome, 1. Revascularization rate was 93% in the AMI group under PECS support. Overall survival rate was 36.4% at one month: it reached 62.5% among non-coronary patients, but only 21.4% in the AMI group (P = 0.02). Weaning was possible by direct heart transplantation in two patients. Additional two patients required implantation of a left ventricular assist device. Pumpless extracorporeal lung assist was used in one case.

CONCLUSION

In this small retrospective study percutaneous emergency circulatory support provided sufficient hemodynamic stabilization in emergency situations. One fifth of AMI patients were saved by immediate restoration of circulation and causal treatment when other means of resuscitation failed. Higher survival rates were noted in non-coronary patients.

Short-term Mechanical Circulatory Support with a Centrifugal Pump - Results of Peripheral Extracorporeal Membrane Oxygenator According to Clinical Situation

Background

A peripheral extracorporeal membrane oxygenator (p-ECMO) has been developed to support patients who are dying due to a serious cardiopulmonary condition. This analysis was planned to define the clinical situation in which the patient benefits most from a p-ECMO.

Material and Methods

Between June 2007 and Aug 2009, a total of 41 adult patients used the p-ECMO. There were 23 males and 18 females (mean age 54.4±15.1 years). All patients had very unstable vital signs with hypoxia and complex cardiac problems. We divided the patients into 4 groups. In the first group, a p-ECMO was used as a bridge to cardiac operation. In the second group, patients did not have the opportunity to undergo any cardiac procedures; nevertheless, they were treated with a p-ECMO. In the third group, patients mostly had difficulty in weaning from CPB (cardiopulmonary bypass) after cardiac operation. The fourth group suffered from many complications, such as pneumonia, bleeding, infections, and LV dysfunction with underlying cardiac problems. All cannulations were performed by the Seldinger technique or cutting down the femoral vessel. A long venous cannula of DLP® (Medtronic Inc, Minneapolis, MN) or RMI® (Edwards Lifesciences LLC, Irvine, CA) was used together with a 17~21 Fr arterial cannula and a 21 Fr venous cannula. As a bypass pump, a Capiox emergency bypass system (EBS®; Terumo, Tokyo, Japan) was used. We attempted to maintain a flow rate of 2.4~3.0 L/min/m² and an activated clotting time (ACT) of around 180 seconds.

Results

Nine patients survived by the use of the p-ECMO. Ten patients were weaned from a p-ECMO but they did not survive, and the remainder had no chance to be weaned from the p-ECMO. The best clinical situation to apply the p-ECMO was to use it as a bridge to cardiac operation and for weaning from CPB after cardiac operation.

Conclusion

Various clinical results were derived by p-ECMO according to the clinical situation. For the best results, early adoption of the p-ECMO for anatomical correction appears important.

A case of iatrogenic ilio-iliac arteriovenous fistula after percutaneous cardiopulmonary support in a patient with a tortuous iliac artery

Percutaneous cardiopulmonary support (PCPS) has repeatedly been used with success as a tool for resuscitation in various life-threatening emergencies. PCPS-related vascular injuries are common, but ilio-iliac arteriovenous fistula (AVF) formation after PCPS has not been reported so far. We experienced a case of iatrogenic ilio-iliac AVF after PCPS, in which association between iliac artery tortuosity and AVF formation was strongly suspected. This case suggests that the risk of iatrogenic iliac AVF should be considered when PCPS is performed, especially in elderly patients whose arteries are frequently tortuous.

The use of percutaneous ECMO support as a 'bridge to bridge' in heart failure patients: a case report

A 65-year-old male with a known history of ischemic cardiomyopathy was admitted to the intensive care unit in cardiogenic shock. Cardiac catheterization revealed bi-ventricular hypokinesis, with an estimated ejection fraction of 15%. Despite moderate inotropic support, the patient's liver enzymes, international normalization ratio (INR), and creatinine became grossly elevated, indicating multi-organ injury from hypoperfusion. Due to the patient's state of shock and probable bleeding complications, a full sternotomy and emergent biventricular assist device insertion was deemed very high risk. In order to achieve hemodynamic stability, a decision was made for extracorporeal membrane oxygenation (ECMO) support. ECMO support was quickly initiated by percutaneous cannulation of the femoral vein and artery. The ECMO circuit was comprised of a Centrimag blood pump and Quadrox-D Safeline-coated membrane oxygenator. With successful perfusion and organ resuscitation, abnormal liver function tests, INR, and creatinine all returned to normal in less than one week. With normal organ function, especially the liver, the patient successfully underwent an implantable left ventricular assist device, HeartMate II LVAD, without requiring mechanical right heart support. Prior to ECMO, the patient was at very high risk of needing biventricular support. Thus, the temporary use of ECMO allowed for a safer and more durable bridge to transplantation. The use of percutaneous ECMO has many advantages, including improving the patient condition and allowing for time to evaluate fully the LVAD patient.

Emergency use of extracorporeal membrane oxygenation in cardiopulmonary failure

Severe pulmonary and cardiopulmonary failure resistant to critical care treatment leads to hypoxemia and hypoxia-dependent organ failure. New treatment options for cardiopulmonary failure are necessary even for patients in outlying medical facilities. If these patients are in need of specialized center treatment, additional emergency medical service has to be carried out quick and safely. We describe our experiences with a pumpless extracorporeal lung assist (PECLA/iLA) for out-of-center emergency treatment of hypercapnic respiratory failure and the use of a newly developed hand-held extracorporeal membrane oxygenation (ECMO) system in cardiac, pulmonary, and cardiopulmonary failure (EMERGENCY-LIFE Support System, ELS System, MAQUET Cardiopulmonary AG, Hechingen, Germany). Between March 2000 and April 2009, we used the PECLA System (n = 20) and the ELS System (n = 33) in adult patients. Cannulation was employed using percutaneous vessel access. The new hand-held ELS System consists of a centrifugal pump and a membrane oxygenator, both mounted on a special holder system for storing on a standard patient gurney for air or ground ambulance transfer. Bedside cannulation processes were uneventful. The PECLA System resulted in sufficient CO(2) removal. In all ECMO patients, oxygen delivery and systemic blood flow could be restored and vasopressor support was markedly down. Hospital survival rate in the PECLA group was 50%, and 61% in the ECMO group. Out-of-center emergency treatment of hypercapnic pulmonary failure with pumpless extracorporeal gas exchange and treatment of cardiac, pulmonary, and cardiopulmonary failure with this new hand-held ECMO device is safe and highlyeffective. Patient outcome in cardiopulmonary organ failure could be improved.

A rodent model of emergency cardiopulmonary bypass resuscitation with different temperatures after asphyxial cardiac arrest

BACKGROUND

The use of emergency cardiopulmonary bypass (ECPB) resuscitation after cardiac arrest may offer hope for survival when standard ACLS therapies fail. However, whether cooling adds benefit to ECPB is unknown and we lack an ECPB rodent model for experimental studies. We sought to (a) develop a 72 h survival rodent model using ECPB to treat asphyxial cardiac arrest and (b) use this new model to evaluate early mild and moderate hypothermia versus normothermia during ECPB resuscitation.

METHODS

After 8 min of normothermic asphyxia, three groups of rats were resuscitated with ECPB at 37 degrees C (NORM), 34 degrees C (MILD) and 30 degrees C (MOD) for 1h (n=10 each). During the second resuscitation hour, ECPB was discontinued, ventilatory support was provided and body temperatures were maintained at 37 degrees C for NORM, 34 degrees C for MILD, and from 30 degrees C gradually up to 34 degrees C in 1h for MOD animals. From hours 3 to 8, body temperature was maintained at 37 degrees C for NORM and 34 degrees C for MILD and MOD animals.

RESULTS

All rats were initially resuscitated by ECPB. After 72 h, neurological outcome and survival in the MILD (60% survival) and MOD (80%) groups were significantly better than in the NORM (0%) group (p<0.05). Overall performance recovery in the MOD group was best (vs. the NORM group), while the MILD group had an intermediate outcome.

CONCLUSIONS

A rodent model of ECPB is feasible and useful for resuscitation studies. The addition of early mild and moderate hypothermia to ECPB resuscitation significantly improves survival compared with normothermic ECPB in rats.

ECMO cannulation controversies and complications

Advances in extracorporeal life support have expanded indications for use extending beyond patients undergoing cardiac surgery. The approach to cannulation in patients requiring extracorporeal membrane oxygenation should be individualized and based on the specific clinical scenario in which the need arises. Adherence to proper techniques of vessel visualization, exposure, and cannulation along with accurate placement of cannulae will optimize flows and minimize complications in this setting. Patients in need of mechanical circulatory support require input from a multidisciplinary team approach with systematic clinical evaluation to optimize outcome. If hemodynamics do not initially permit the successful separation from mechanical support, then a systematic search for potentially reversible patient and/ or pump related factors should be undertaken. The success of this therapy is predicated on patient selection, a multidisciplinary team approach in the intensive care unit, adherence to precise technical principles, and repeated patient evaluation.

[Percutaneous extracorporeal life support in acute severe hemodynamic collapses: single centre experience in 100 consecutive patients]

BACKGROUND

Extracorporeal life support (ECLS) is a circulatory assistance device that is increasingly used in adults undergoing cardiopulmonary arrest (CPA) or hemodynamic collapse when conventional therapies fail.

OBJECTIVES

To assess the feasibility and outcomes of 100 consecutive arteriovenous percutaneous ECLS procedures at the Grenoble University Hospital between January 2002 and September 2007.

METHODS

Monocentric descriptive registry with one-year prospective follow-up.

RESULTS

An ECLS device was successfully used in 93% of patients. Its indication was cardiogenic shock in 50% of the cases, CPA in 38% of the cases and unsuccessful weaning of cardiopulmonary bypass (CPB) after cardiothoracic surgery in 12% of the cases. Direct complications of ECLS were observed in 56% of patients, the most frequent being hemorrhage at the intravenous puncture site requiring red blood cell transfusions (26%), and lower limb ischemia (19%). Weaning from ECLS was achieved in 33 patients (44% cardiogenic shocks, 13% CPAs, 50% CPB weaning failures) and 20 patients were discharged from the hospital (26% cardiogenic shocks, 10.5% CPAs and 25% CPB weaning failures). All are still living without any serious sequelae (mean follow-up period of 16.8 months).

CONCLUSION

The use of ECLS in CPA patients, especially with cardiogenic shock, is feasible with satisfactory survival rates, given the extreme severity of their initial state.

Patient selection and therapeutic strategy for emergency percutaneous cardiopulmonary system in cardiopulmonary arrest patients

BACKGROUND

To clarify the appropriate application and therapeutic strategy for the percutaneous cardiopulmonary system (PCPS) in patients in cardiopulmonary arrest (CPA), the effects of the duration of cardiopulmonary resuscitation (CPR), diagnosis of underlying diseases, subsequent intervention and complications were retrospectively investigated for the correlation between discharge or death of patients. The patients were treated under an identical therapeutic PCPS protocol.

METHODS AND RESULTS

The 69 CPA patients [55 males (78.6%), 14 females; age, 55.0 +/-15.3 years; age range 15-79 years, 50 in-hospital CPA (I-CPA) and 19 out-of-hospital CPA (O-CPA) patients] were treated with emergency PCPS. The mean duration of CPR was 43.6 +/-37.4 min. Of 18 discharged patients (26.1%), 14 had I-CPA and 4 had O-CPA. Significant factors in the discharge of patients were confirmed diagnosis, subsequent treatment and prevention of complications associated with PCPS.

CONCLUSIONS

Appropriate patient selection for PCPS in cases of O-CPA is likely to give a similar survival rate as for I-CPA. Patient selection and reversibility of the underlying disease and clinical state after starting PCPS affect the prognosis. Aggressive diagnosis and therapy for the underlying disease and prevention of complications associated with PCPS are essential factors in successful discharge of patients. Patients with an unknown etiology are not expected to fully recover, despite PCPS.

The efficacy of rewarming with a portable and percutaneous cardiopulmonary bypass system in accidental deep hypothermia patients with hemodynamic instability

OBJECTIVE

Accidental deep hypothermia (ADH)--a condition in which the core body temperature is less than 28 degrees C--is a medical emergency; the mortality rates for ADH remain high. The efficacy of cardiopulmonary bypass (CPB) rewarming has been proved in ADH patients with cardiopulmonary arrest; however, its efficacy in the ADH patients without cardiopulmonary arrest remains controversial. In our study, we evaluated the efficacy of portable percutaneous cardiopulmonary bypass (PPCPB) for rewarming and providing cardiovascular support in the hemodynamically unstable ADH patients without cardiopulmonary arrest.

METHODS

Between April 2001 and March 2006, we performed a retrospective study at Tokai University, Kanagawa, Japan. We studied 24 ADH patients without cardiopulmonary arrest (male:female ratio, 15:9; mean age, 68.5 +/- 12.9 years) with hemodynamic instability who had not developed intracranial hemorrhage. We evaluated the efficacy of PPCPB rewarming by estimating the mean time of initiation of PPCPB after admission, rewarming speed, the success rate of rewarming, the rate of weaning from PPCPB, the incidence of ventricular fibrillation (Vf) during rewarming, complications associated with PPCPB, mortality rate, and the Glasgow Outcome Scale (GOS) scores of the patients who survived.

RESULTS

The mean time of initiation of PPCPB after admission was 41.9 +/- 7.9 minutes. The rewarming speed was 4.0 +/- 1.5 degrees C/h. A 100% success rate was achieved after the rewarming procedure, whereas the rate of weaning from PPCPB was 91.7%. Vf during rewarming developed in one case; however, electrical defibrillation was possible. No direct complications of PPCPB were observed. The mortality rate was 12.5% (3/24). The GOS scores of the patients who survived were as follows: 5 points, 17 cases; 4 points, 3 cases; and 3 points, 1 case.

CONCLUSION

PPCPB rewarming is a clinically efficacious procedure for rewarming and providing cardiovascular support in hemodynamically unstable ADH patients without cardiopulmonary arrest who have not developed intracranial hemorrhage.

Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis

BACKGROUND

Extracorporeal life-support as an adjunct to cardiac resuscitation has shown encouraging outcomes in patients with cardiac arrest. However, there is little evidence about the benefit of the procedure compared with conventional cardiopulmonary resuscitation (CPR), especially when continued for more than 10 min. We aimed to assess whether extracorporeal CPR was better than conventional CPR for patients with in-hospital cardiac arrest of cardiac origin.

METHODS

We did a 3-year prospective observational study on the use of extracorporeal life-support for patients aged 18-75 years with witnessed in-hospital cardiac arrest of cardiac origin undergoing CPR of more than 10 min compared with patients receiving conventional CPR. A matching process based on propensity-score was done to equalise potential prognostic factors in both groups, and to formulate a balanced 1:1 matched cohort study. The primary endpoint was survival to hospital discharge, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00173615.

FINDINGS

Of the 975 patients with in-hospital cardiac arrest events who underwent CPR for longer than 10 min, 113 were enrolled in the conventional CPR group and 59 were enrolled in the extracorporeal CPR group. Unmatched patients who underwent extracorporeal CPR had a higher survival rate to discharge (log-rank p<0.0001) and a better 1-year survival than those who received conventional CPR (log rank p=0.007). Between the propensity-score matched groups, there was still a significant difference in survival to discharge (hazard ratio [HR] 0.51, 95% CI 0.35-0.74, p<0.0001), 30-day survival (HR 0.47, 95% CI 0.28-0.77, p=0.003), and 1-year survival (HR 0.53, 95% CI 0.33-0.83, p=0.006) favouring extracorporeal CPR over conventional CPR.

INTERPRETATION

Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin.

Extracorporeal cardiopulmonary resuscitation in refractory pediatric cardiac arrest

The purpose of this article is to discuss the indications for extracorporeal cardiopulmonary resuscitation (ECPR), physiologic and mechanical issues that arise in patients managed with ECPR, and optimal patient selection for ECPR. ECPR can provide very good outcomes for some children who, in all likelihood, would otherwise have died. Having the capability to routinely offer ECPR represents an enormous institutional commitment of people and resources. For ECPR to be successful, it must be rapidly deployed, patients must be selected with care, and consistently excellent conventional CPR must take place while awaiting ECPR.

Cardiopulmonary bypass as an adjunct for the noncardiac surgeon

The use of cardiopulmonary bypass (CPB) in noncardiac surgical settings has been increasingly developed and has greatly benefited noncardiac surgeon. A few years after the advent of CPB as well as profound hypothermic circulatory arrest in the early years, it was employed by neurosurgeons in cerebrovascular surgery and by general thoracic surgeons in carinal tumor resection. Indications for CPB were extended and modified year after year. It has facilitated not only the surgical management by surgeons of lesions that cannot be managed safely and effectively by conventional techniques, or conventional techniques carry significant risks to the patient, but also the preservation of the viability of multiple organ procurement, the practice of isolated limb perfusion for the treatment of malignancies of the extremities, and emergent cardiopulmonary resuscitation. Owing to the complications arising from CPB and profound hypothermic circulatory arrest, such as postoperative bleeding, coagulopathy, and neurologic deficits, efforts have been made to avoid these common hazards. Thus, innovative techniques including extracorporeal membrane oxygenation, percutaneous cardiopulmonary support, venovenous bypass, normothermic CPB, and minimally invasive approaches have emerged and played an important role as alternatives of standard CPB in decreasing morbidity and mortality and improving survival.

Full recovery of an avalanche victim with profound hypothermia and prolonged cardiac arrest treated by extracorporeal re-warming

Survival of hypothermic avalanche victims with cardiac arrest is rare. This report describes full recovery of a 29-year-old backcountry skier completely buried for 100 min at 3.0m (9.8 ft) depth. On extrication he was unconscious, but breathing spontaneously into an air pocket; core body temperature measured 22.0 degrees C (71.6 degrees F). He was intubated and ventilated on site. Ventricular fibrillation commenced during helicopter transportation, whereby chest compression was lacking for 15 min. At the nearest hospital continuous cardiopulmonary resuscitation was initiated, but defibrillation failed. Tympanic core body temperature measurement confirmed life-threatening hypothermia of 21.7 degrees C (71.1 degrees F) and serum K(+) was 4.3 mmol/l, necessitating transferral to a hospital with cardiopulmonary bypass facilities. Defibrillation finally succeeded following re-warming, by femoral veno-arterial bypass, to 34.5 degrees C (94.1 degrees F). Total duration of cardiac arrest was 150 min. The patient developed pulmonary oedema, treated by extracorporeal membrane oxygenation, but progressed well and was discharged from hospital on day 17, fit to resume professional and social activities. Follow-up cerebral magnetic resonance imaging 2 years after avalanche burial demonstrated only minimal changes attributable to unrelated, prior cranial trauma. Extensive neurological and psychological investigations gave excellent results. This report confirms previous literature that an air pocket with patent airways is essential for survival of a completely buried avalanche victim after 35 min and endorses the recommended management strategies of the International Commission for Mountain Emergency Medicine ICAR MEDCOM. In particular, all hypothermic victims extricated with an air pocket and free airways must be treated optimistically, even despite prolonged cardiac arrest. This remarkable case documents the fastest drop in core temperature ever recorded during snow burial, namely 9.0 degrees C (16.2 degrees F)/h, and the second-lowest reversible core temperature in avalanche literature.

Prolonged extracorporeal membrane oxygenation-assisted support provides improved survival in hypothermic patients with cardiocirculatory arrest

OBJECTIVE

Extracorporeal circulation is considered the gold standard in the treatment of hypothermic cardiocirculatory arrest; however, few centers use extracorporeal membrane oxygenation instead of standard extracorporeal circulation for this indication. The aim of this study was to evaluate whether extracorporeal membrane oxygenation-assisted resuscitation improves survival in patients with hypothermic cardiac arrest.

METHODS

A consecutive series of 59 patients with accidental hypothermia in cardiocirculatory arrest between 1987 and 2006 were included. Thirty-four patients (57.6%) were resuscitated by standard extracorporeal circulation, and 25 patients (42.4%) were resuscitated by extracorporeal membrane oxygenation. Accidental hypothermia was caused by avalanche in 22 patients (37.3%), drowning in 22 patients (37.3%), exposure to cold in 8 patients (13.5%), and falling into a crevasse in 7 patients (11.9%). Multivariate logistic regression analysis was used to compare extracorporeal membrane oxygenation with extracorporeal circulation resuscitation, with adjustment for relevant parameters.

RESULTS

Restoration of spontaneous circulation was achieved in 32 patients (54.2%). A total of 12 patients (20.3%) survived hypothermia. In the extracorporeal circulation group, 64% of the nonsurviving patients who underwent restoration of spontaneous circulation died of severe pulmonary edema, but none died in the extracorporeal membrane oxygenation group. In multivariate analysis, extracorporeal membrane oxygenation-assisted resuscitation showed a 6.6-fold higher chance for survival (relative risk: 6.6, 95% confidence interval: 1.2-49.3, P = .042). Asphyxia-related hypothermia (avalanche or drowning) was the most predictive adverse factor for survival (relative risk: 0.09, 95% confidence interval: 0.01-0.60, P = .013). Potassium and pH failed to show statistical significance in the multivariate analysis.

CONCLUSIONS

Extracorporeal rewarming with an extracorporeal membrane oxygenation system allows prolonged cardiorespiratory support after initial resuscitation. Our data indicate that prolonged extracorporeal membrane oxygenation support reduces the risk of intractable cardiorespiratory failure commonly observed after rewarming.

Extracorporeal life support to terminate refractory ventricular tachycardia

OBJECTIVE

Extracorporeal life support (ECLS) has been applied successfully to patients with cardiopulmonary failure in extreme situations. Refractory ventricular tachycardia has high mortality and morbidity rates if not terminated in time. This study describes our preliminary experiences in using ECLS to treat patients with refractory ventricular tachycardia.

DESIGN

Retrospective chart review.

SETTING

Hospital.

PATIENTS

Eleven patients suffering from ventricular tachycardia refractory to antiarrhythmia agents and cardioversion attempts.

INTERVENTIONS

From January 2002 to December 2004, 11 patients suffering from ventricular tachycardia refractory to antiarrhythmia agents and cardioversion attempts were treated with ECLS. Mean patient age was 31 +/- 21 yrs (range, 3-69 yrs). The triggering events were acute myocarditis (n = 8), coronary artery spasm (n = 1), and hypoxemia secondary to acute respiratory distress syndrome (n = 2). Nine (82%) patients received venoarterial mode support and the remaining two (18%) were supported with venovenous mode to correct hypoxemia. Pump flow was first maximized (mean, 3800 +/- 1100 mL/min) to unload the heart, and an intra-aortic balloon pump was used to deal with the increased afterload (n = 8).

MEASUREMENTS AND MAIN RESULTS

Mean ventricular tachycardia duration before ECLS was 50 +/- 16 mins (range, 20-75 mins) and soon converted to a sinus rhythm following ECLS deployment, including four patients who experienced spontaneous recovery without attempted cardioversion, in a mean of 7.4 mins (range, 1-20 mins). Four patients required temporary pacing but none needed a permanent pacemaker after recovery. Mean duration of ECLS support was 119 +/- 69 hrs (range, 12-250 hrs). We excluded one patient who had permanent brain injury and another who succumbed to multiple organ failure. Nine (82%) patients were weaned and discharged with normal cardiac function. No recurrent ventricular tachycardia attack but one recurrent cardiomyopathy (ejection fraction = 15%) was reported during a mean 42-month follow-up.

CONCLUSIONS

Using ECLS to terminate refractory ventricular tachycardia proved effective for selected patients when conventional therapeutic options were exhausted. Early deployment of ECLS to prevent secondary organ injury, maintain sufficient cardiac unloading, and avoid complications during ECLS support was central to successful outcomes.

Mechanical Circulatory Support for Cardiogenic Shock Complicating Acute Myocardial Infarction: An Experimental and Clinical Review

Cardiogenic shock (CS) occurs in 7% to 10% of cases after acute myocardial infarction and remains the most common cause of death in these patients. Despite aggressive treatment regimens such as fibrinolysis and percutaneous transluminal coronary angioplasty, mortality rates from CS remain extremely high. It has been shown that intra-aortic balloon pumping can result in initial hemodynamic stabilization. However, in the majority of studies, death was merely delayed. In recent years, efforts have been made to develop ventricular devices (LVAD) capable of providing complete short-term hemodynamic support. Seventeen major studies of LVAD support for CS complicating acute myocardial infarction are reported in the literature, with a mean weaning and survival rate of 58.5% and 40%, respectively. Patients considered in these studies are difficult to compare in terms of demographic and anatomic data, but taking these considerations into account, LVAD support seems to give no survival improvement in these patients compared with early reperfusion alone or associated with intra-aortic balloon pumping. Data emerging from experimental studies of acute myocardial infarction supported with LVAD are intriguing. In this review, we report the LVAD experience in the CS setting, starting from percutaneous extracorporeal support up to bridge therapy with implantable devices.

Emergency feasibility in medical intensive care unit of extracorporeal life support for refractory cardiac arrest

OBJECTIVE

To report the feasibility, complications, and outcomes of emergency extracorporeal life support (ECLS) in refractory cardiac arrests in medical intensive care unit (ICU).

DESIGN AND SETTING

Prospective cohort study in the medical ICU in a university hospital in collaboration with the cardiosurgical team of a neighboring hospital.

PATIENTS

Seventeen patients (poisonings: 12/17) admitted over a 2-year period for cardiac arrest unresponsive to cardiopulmonary resuscitation (CPR) and advanced cardiac life support, without return of spontaneous circulation.

INTERVENTIONS

ECLS femoral implantation under continuous cardiac massage, using a centrifugal pump connected to a hollow-fiber membrane oxygenator.

MEASUREMENTS AND RESULTS

Stable ECLS was achieved in 14 of 17 patients. Early complications included massive transfusions (n=8) and the need for surgical revision at the cannulation site for bleeding (n=1). Four patients (24%) survived at medical ICU discharge. Deaths resulted from multiorgan failure (n=8), thoracic bleeding(n=2), severe sepsis (n=2), and brain death (n=1). Massive hemorrhagic pulmonary edema during CPR (n=5) and major capillary leak syndrome (n=6) were observed. Three cardiotoxic-poisoned patients (18%, CPR duration: 30, 100, and 180 min) were alive at 1-year follow-up without sequelae. Two of these patients survived despite elevated plasma lactate concentrations before cannulation (39.0 and 20.0 mmol/l). ECLS was associated with a significantly lower ICU mortality rate than that expected from the Simplified Acute Physiology Score II (91.9%) and lower than the maximum Sequential Organ Failure Assessment score (>90%).

CONCLUSIONS

Emergency ECLS is feasible in medical ICU and should be considered as a resuscitative tool for selected patients suffering from refractory cardiac arrest.

Successful extracorporeal life support in cardiac arrest with recurrent ventricular fibrillation unresponsive to standard cardiopulmonary resuscitation

Extracorporeal life support has been used as an extension of conventional cardiopulmonary resuscitation (CPR). However, the appropriate indications for extracorporeal CPR (ECPR) including the duration of CPR are unknown. We present a case of a male, 37-year-old out-of-hospital cardiac arrest patient who received prolonged CPR followed by ECPR. Despite advanced cardiac life support, he did not regain a sustained spontaneous circulation and had recurrent ventricular fibrillation (VF) during the prolonged CPR. VF was unresponsive to CPR, defibrillation, adrenaline (epinephrine), and antiarrhythmics. The CPR time before ECPR was approximately 2h. During extracorporeal life support, the VF did not recur and percutaneous coronary angioplasty was achieved. Ultimately, the patient was discharged without neurological complications. Although cardiac arrest occurred out-of-hospital and CPR was performed for a long time, a patient might be a candidate for ECPR if perfusing rhythms are restored transiently but not successfully maintained due to recurrent VF. ECPR may be used for VF unresponsive to standard CPR techniques.

Systematic review of percutaneous cardiopulmonary bypass for cardiac arrest or cardiogenic shock states

BACKGROUND

Cardiogenic shock and cardiac arrest are common, lethal, debilitating and costly. Percutaneous cardiopulmonary bypass is an innovative strategy for treating these disorders that consists of rapid initiation of cardiopulmonary bypass and extracorporeal maintenance of circulation until restoration of an effective cardiac output. Multiple case reports suggest that percutaneous bypass is efficacious in patients with these disorders but these experiences have not been collated. Therefore, we have reviewed systematically the published experience with percutaneous bypass in patients with cardiogenic shock or cardiac arrest.

OBJECTIVES

The objectives were to describe the proportion of patients with cardiogenic shock or cardiac arrest who achieved restoration of spontaneous circulation or survival to discharge with percutaneous bypass. A secondary objective was to describe adverse effects associated with percutaneous bypass, if feasible.

DESIGN

Articles were identified by using a comprehensive search of English-language MEDLINE from 1966 to September 2005.

PATIENTS

Individuals in cardiogenic shock or cardiac arrest.

INTERVENTIONS

Percutaneous cardiopulmonary bypass.

ANALYSIS

Effects were summarized as inverse-variance weighted means, standard errors, median and interquartile range.

RESULTS

Included were 85 studies of 1494 patients with cardiogenic shock, cardiac arrest or both. Studies were case reports, case-series or case-control studies of heterogeneous interventions in heterogeneous patients. The proportion of patients weaned was mean, 76.8+/-4.2%, and median, 66.0% (IQR 50%, 100%). The proportion of patients who survived to discharge was mean, 47.4+/-4.5%, and median 40.0% (IQR 20%, 75%). Fifty-two studies included 533 patients in cardiogenic shock. The proportion of patients who survived to discharge was mean, 51.6+/-6.5%, and median 38.5% (IQR 23.4%, 76.3%). Fifty-four studies included 675 patients in cardiac arrest. The proportion of patients who survived to discharge was mean, 44.9+/-6.7%, and median, 42.3% (IQR 15.4%, 75%). Five studies with 286 subjects had both patients with cardiogenic shock or cardiac arrest.

CONCLUSIONS

Percutaneous bypass is an efficacious intervention in patients with cardiac arrest or cardiogenic shock. Adequately-powered experimental studies of current percutaneous bypass technologies are required to demonstrate whether it is safe, effective and cost-effective.

Improved survival after cardiac arrest using emergent autopriming percutaneous cardiopulmonary support

BACKGROUND

Emergent percutaneous cardiopulmonary support (PCPS) has the potential to rescue patients in cardiac arrest who might otherwise die. We retrospectively reviewed the results of PCPS using preassembled, heparin-coated, and autopriming devices in patients in cardiac arrest.

METHODS

From November 2003 to July 2005, 22 patients in cardiac arrest underwent PCPS using the Capiox emergent bypass system (Terumo, Tokyo, Japan). The mean +/- SD age was 63 +/- 14 (range, 31 to 85) years. In six patients, the underlying disease causing cardiac arrest was not diagnosed before PCPS. The procedure involved 14 to 21 Fr percutaneous femoral arterial cannulae and 17 to 28 Fr percutaneous femoral long venous cannulae. The mean duration of cardiopulmonary resuscitation before PCPS was 48.5 +/- 29.0 (range, 15 to 143) minutes. An intraaortic balloon pump was used concomitantly in six patients.

RESULTS

Fourteen patients received additional surgical or interventional procedures during PCPS. Thirteen (59%) patients could be weaned off PCPS after 52.3 +/- 47.8 (range, 4 to 141) hours of support. Twelve complications occurred in 11 patients, including eight related to PCPS: low perfusion flow (two), gastrointestinal bleeding (two), surgical wound bleeding (one), femoral arterial catheter dislodgement (one), hemolysis with acute renal failure (one), and mitral valve thrombus (one). Nine patients (41%) were discharged from hospital without neurologic complications. The incidence of complications differed in comparisons between patients who survived and did not survive.

CONCLUSIONS

The use of preassembled, heparin-coated and autoprimed devices enabled us to rescue in-hospital cardiac arrest patients who might have died without this procedure.

Outcome evaluation of the bridge-to-bridge concept in patients with cardiogenic shock

BACKGROUND

Patients with cardiogenic shock can be stabilized by percutaneous implantation of extracorporeal membrane oxygenation (ECMO). If weaning from ECMO is impossible, the implantation of a ventricular assist device (VAD) is required. Patients either go for recovery of myocardial function (bridge to recovery) or for heart transplantation (bridge to transplant).

METHODS

One hundred thirty-one patients were supported with ECMO between March 1995 and November 2005. Reasons for ECMO implantation were acute heart failure, acute or chronic heart failure, and postcardiotomy heart failure. In 28 patients, subsequent VAD implantation was necessary (bridge to bridge concept).

RESULTS

Fourteen bridge to bridge patients (50%) became long-time survivors with a mean follow-up of 39 months. Risk factors for mortality were status post-cardiopulmonary resuscitation and elevated lactate and bilirubin levels before VAD implantation. Complications after ECMO and VAD implantation were bleeding and thromboembolic events. The most common cause of death was multiorgan failure.

CONCLUSIONS

Bridge to bridge is a successful concept for selected patients with cardiogenic shock. During ECMO support, patients can be evaluated for comorbidities. For patients with a combination of risk factors (status post-cardiopulmonary resuscitation, elevated lactate levels, and impaired liver function), VAD implantation should be considered very carefully.

A Novel Femoral Arterial Cannula to Prevent Limb Ischemia During Cardiopulmonary Support: Preliminary Report of Experimental and Clinical Experiences

Distal limb ischemia may occur as a serious complication related to the use of femoral cannulation during veno-arterial cardiopulmonary support (CPS). We developed a simple cannula for femoral arterial cannulation with two holes in the side wall, which could provide the distal limb blood flow without additional cannulation or surgical procedure. This cannula can be inserted into the femoral artery by routine Seldinger technique. The distal blood flow from the side holes can be confirmed by Doppler detector without specialized techniques. In porcine experimental model, the distance between the position where the blood flow was first detected and those where the blood leakage took place was at least more than 10 mm. When this cannula and its side holes were adequately positioned, the mean distal limb flow ranged from 75 to 90 mL/min under CPS at a flow of 1.5 L/min. We employed this cannula for six patients in clinical settings. Three patients showed a good distal limb blood flow at the introduction position without its adjustment. The other three patients showed distal limb ischemia at the introduction position, but the limb ischemia was soon recovered after a slight adjustment of its position. There was no blood leakage from the percutaneous entry into the artery in all cases. We currently use this cannula as the first choice for patients undergoing a prolonged CPS.

Open and closed chest extrathoracic cannulation for cardiopulmonary bypass and extracorporeal life support: methods, indications, and outcomes

Extrathoracic cannulation to establish cardiopulmonary bypass has been widely applied in recent years and includes: (a) repeat surgery, (b) minimally invasive surgery, and (c) cases with diseased vessels such as porcelain, aneurysmal, and dissecting aorta. In addition, the success and relative ease of peripheral cannulation, among other technological advances, has permitted the development of closed chest extracorporeal life support, in the form of cardiopulmonary support and extracorporeal membrane oxygenation. With this development have come applications for cardiopulmonary bypass based support outside the traditional cardiac theatre setting, including emergency circulatory support for patients in cardiogenic shock and respiratory support for patients with severely impaired gas exchange. This review summarises the approach to extrathoracic cannulation for the generalist.

Analysis of the outcome for patients experiencing myocardial infarction and cardiopulmonary resuscitation refractory to conventional therapies necessitating extracorporeal life support rescue*

OBJECTIVE

To analyze the results of acute myocardial infarction (AMI) complicated with refractory shock necessitating extracorporeal life support (ECLS) rescue and to search for associated risk factors.

DESIGN

Retrospective review of our 9-yr experience with patients initially presenting with AMI with shock necessitating ECLS rescue; analysis of patient outcomes.

SETTING

A university-affiliated tertiary referral medical center.

PATIENTS

Between 1994 and 2003 inclusively, 36 consecutive patients (age [mean +/- sd], 57 +/- 10 yrs) with AMI complicated by refractory shock and undergoing cardiopulmonary resuscitation (CPR) necessitating emergent ECLS rescue were enrolled in this study.

INTERVENTION

All patients underwent CPR before ECLS, although 30 patients (83.3%) received ECLS during CPR because spontaneous circulation failed to return. All patients underwent intraaortic counterpulsation either before or following rescue. Seven patients underwent angioplasty only, and one underwent heart transplantation without any intervention. Twenty-eight patients underwent coronary artery bypass grafting (CABG), in which the beating-heart technique was used for 20 patients.

MEASUREMENTS AND MAIN RESULTS

The pre-ECLS blood lactate level was high (13.4 +/- 8.5 mmol/L), as was the inotropic score (121.4 +/- 117.3 microg/kg/min). Twenty-five patients (69.4%) were successfully weaned off ECLS, and 12 (48%) survived to discharge (one had a neurologic deficit). The overall mortality rate was 66.7%. A lower inotropic score, reduced blood lactate level, shorter CPR duration, surgical revascularization, and a reduced total maximal Sepsis-related Organ Failure Assessment (SOFA) score were noted among survivors. Liver failure, central nervous system failure, and renal failure mainly occurred in nonsurvivors after ECLS. The technique used for surgical revascularization (beating heart or arrested heart) did not influence the outcome. ECLS is associated with a lower mortality rate than that expected (>90%) from the resultant total maximal SOFA score (16.6 +/- 3.0).

CONCLUSIONS

: AMI complicated with refractory shock remains associated with a high mortality rate, even following ECLS rescue, although ECLS might afford a better chance of survival. The SOFA score can be applied to ECLS condition as a reference point for predicting outcome.

LIFEBRIDGE: A Portable, Modular, Rapidly Available “Plug-and-Play” Mechanical Circulatory Support System

PURPOSE

We describe the LIFEBRIDGE, a portable, modular, rapidly available "plug-and-play" mechanical circulatory support system, and report its experimental safety evaluation.

DESCRIPTION

The modular construction consists of a disposable patient module with cardiopulmonary bypass circuit, control module, and base module with power supply, embedded PC, and user interface. The system weighs about 20 kg, has a modular design, and has semi-automatic priming that allows action within 5 minutes, and a 7-step air elimination program that prevents air embolization.

EVALUATION

In eight pigs (85 +/- 10 kg) we investigated this system using central (right atrium and ascending aorta) cannulation (n = 4) or peripheral (iliac) cannulation (n = 4). Pump flows were 5.7 +/- 0.2 L/min with central and 4.1 +/- 0.2 L/min with peripheral cannulation, yielding sufficient animal perfusion and gas exchange. Using an intraaortic 8-MHz Doppler device, we demonstrated that venous air boluses of up to 100 mL were effectively removed, thus avoiding air embolization. Changing heights between animals and LIFEBRIDGE did not affect its proper action.

CONCLUSIONS

This initial evaluation demonstrates that the LIFEBRIDGE is rapidly available, provides adequate perfusion and gas exchange, and operates safely even under simulated transport conditions.

Choc peranesthésique d'étiologie probablement anaphylactique à l'atracurium traité avec succès par circulation extracorporelle

We report the case of a 55-year-old woman ASA 2 scheduled for a cholecystectomy, who presented 25 minutes after the induction, a circulatory arrest probably due to a cardiac anaphylaxis attributed to atracurium. After 60 minutes of futile resuscitation without any spontaneous cardiac rhythm a percutaneous cardiopulmonary bypass (CPB) was initiated. Twenty minutes later and after three external electric shocks electric cardiac activity returned normal. The weaning was possible 120 minutes later with catecholamine support. She left the intensive care unit on postoperative day seven after a laparotomy secondary to splenic injury due to intensive cardiopulmonary resuscitation. She was discharged home without any neurologic or cardiac sequellae. Biological assessment done during the circulatory arrest and cutaneous tests performed ten weeks later confirmed an isolated allergy to atracurium. CPB is the most efficient support in case of reversible cardiac arrest but unfortunately the less accessible outside from cardiac surgery unit.

Back from Irreversibility: Extracorporeal Life Support for Prolonged Cardiac Arrest

BACKGROUND

The survival of patients after prolonged cardiac arrest is still inadequate. Extracorporeal life support (ECLS) represents an alternative therapeutic method for patients who do not respond to conventional cardiopulmonary cerebral resuscitation. This technology is used to support the circulation of a patient with severe cardiac failure.

METHODS

Between June 1997 and January 2003, 40 ECLS procedures were performed in patients who presented with refractory cardiac arrest. During external cardiac massage, the patient was connected to an extracorporeal circuit by the insertion of an arterial and venous cannula through the femoral vessels. The extracorporeal circuit included a centrifugal pump and an oxygenator. Mean age was 42 +/- 15 years; the average time of external cardiac massage was 105 +/- 44 minutes.

RESULTS

Once the circulation was restored, 22 patients were disconnected from the extracorporeal circulation because of brain death or multiorgan failure; after 24 hours, among the 18 survivors, 6 were weaned off the pump, 9 were bridged to a ventricular assist device, and 2 patients were directly bridged to cardiac transplantation. Eight patients are alive and without any sequelae at 18 month's follow-up.

CONCLUSIONS

In prolonged cardiac arrest with failing conventional measures, rescue by extracorporeal support provides an ultimate therapeutic option with a good outcome in survivors. Our results encourage the wider application of ECLS for refractory cardiocirculatory arrest in selected patients. The high rate of neurologic death needs further improvements in the early phase of resuscitation maneuvers.

Survival outcomes after extracorporeal cardiopulmonary resuscitation instituted during active chest compressions following refractory in-hospital pediatric cardiac arrest

OBJECTIVE

To report survival outcomes and to identify factors associated with survival following extracorporeal cardiopulmonary resuscitation for in-hospital pediatric cardiac arrest.

DESIGN

Retrospective chart review, consecutive case series.

MAIN OUTCOME MEASURE

Survival to hospital discharge.

RESULTS

During a 7-yr study period, there were 66 cardiac arrest events in 64 patients in which a child was cannulated for extracorporeal membrane oxygenation during active cardiopulmonary resuscitation with chest compressions. A total of 33 of 66 events (50%) resulted in the child being decannulated and surviving at least 24 hrs; 21 of 64 (33%) children undergoing extracorporeal cardiopulmonary resuscitation survived to hospital discharge. A total of 19 of 43 children with isolated heart disease compared with two of 21 children with other medical conditions survived to hospital discharge (p <.01). Pediatric Cerebral Performance Category and Pediatric Overall Performance Category were determined for survivors >2 months old. Five of ten extracorporeal cardiopulmonary resuscitation survivors >2 months old had no change in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category compared with admission. Three of six extracorporeal cardiopulmonary resuscitation patients who survived after receiving >60 mins of chest compressions before extracorporeal cardiopulmonary resuscitation had grossly intact neurologic function. During a 2-yr period in the same hospital, no patient who received >30 mins of cardiopulmonary resuscitation without extracorporeal cardiopulmonary resuscitation survived. In this case series, age, weight, or duration of chest compressions before extracorporeal cardiopulmonary resuscitation did not correlate with survival.

CONCLUSIONS

Extracorporeal cardiopulmonary resuscitation can be used to successfully resuscitate selected children following refractory in-hospital cardiac arrest, and can be implemented during active cardiopulmonary resuscitation. Intact neurologic survival can sometimes be achieved, even when the duration of in-hospital cardiopulmonary resuscitation is prolonged. In this series, children with isolated heart disease were more likely to survive following extracorporeal cardiopulmonary resuscitation than were children with other medical conditions.