A systematic literature review and meta-analysis of the effectiveness of extracorporeal-CPR versus conventional-CPR for adult patients in cardiac arrest

In-Depth Extracorporeal Cardiopulmonary Resuscitation in Adult Out-of-Hospital Cardiac Arrest

The use of extracorporeal cardiopulmonary resuscitation (E‐CPR) for the treatment of patients with out‐of‐hospital cardiac arrest who do not respond to conventional cardiopulmonary resuscitation CPR) has increased significantly in the past 10 years, in response to case reports and observational studies reporting encouraging results. However, no randomized controlled trials comparing E‐CPR with conventional CPR have been published to date. The evidence from systematic reviews of the available observational studies is conflicting. The inclusion criteria for published E‐CPR studies are variable, but most commonly include witnessed arrest, immediate bystander CPR, an initial shockable rhythm, and an estimated time from CPR start to establishment of E‐CPR (low‐flow time) of <60 minutes. A shorter low‐flow time has been consistently associated with improved survival. In an effort to reduce low‐flow times, commencement of E‐CPR in the prehospital setting has been reported and is currently under investigation. The provision of an E‐CPR service, whether hospital based or prehospital, carries considerable cost and technical challenges. Despite increased adoption, many questions remain as to which patients will derive the most benefit from E‐CPR, when and where to implement E‐CPR, optimal post‐arrest E‐CPR care, and whether this complex invasive intervention is cost‐effective. Results of ongoing trials are awaited to determine whether E‐CPR improves survival when compared with conventional CPR.

Prospective observational study of mechanical cardiopulmonary resuscitation, extracorporeal membrane oxygenation and early reperfusion for refractory cardiac arrest in Sydney: the 2CHEER study

BACKGROUND

Patients with prolonged cardiac arrest that is not responsive to conventional cardiopulmonary resuscitation have poor outcomes. The use of extracorporeal membrane oxygenation (ECMO) in refractory cardiac arrest has shown promising results in carefully selected cases. We sought to validate the results from an earlier extracorporeal cardiopulmonary resuscitation (ECPR) study (the CHEER trial).

METHODS

Prospective, consecutive patients with refractory in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) who met predefined inclusion criteria received protocolised care, including mechanical cardiopulmonary resuscitation, initiation of ECMO, and early coronary angiography (if an acute coronary syndrome was suspected).

RESULTS

Twenty-five patients were enrolled in the study (11 OHCA, 14 IHCA); the median age was 57 years (interquartile range [IQR], 39-65 years), and 17 patients (68%) were male. ECMO was established in all patients, with a median time from arrest to ECMO support of 57 minutes (IQR, 38-73 min). Percutaneous coronary intervention was performed on 18 patients (72%). The median duration of ECMO support was 52 hours (IQR, 24-108 h). Survival to hospital discharge with favourable neurological recovery occurred in 11/25 patients (44%, of which 72% had IHCA and 27% had OHCA). When adjusting for lactate, arrest to ECMO flow time was predictive of survival (odds ratio, 0.904; P = 0.035).

CONCLUSION

ECMO for refractory cardiac arrest shows promising survival rates if protocolised care is applied in conjunction with predefined selection criteria.

Role of extracorporeal cardiopulmonary resuscitation in adults

Extracorporeal cardiopulmonary resuscitation (ECPR) has been performed with increasing frequency worldwide to improve the low survival rate of conventional cardiopulmonary resuscitation (CCPR). Several studies have shown that among patients who experience in-hospital cardiac arrest, better survival outcomes and neurological outcomes can be expected after ECPR than after CCPR. However, studies have not clearly shown a short-term survival benefit of ECPR for patients who experience out-of-hospital cardiac arrest. Favorable outcomes are associated with a shorter low-flow time, an initial shockable rhythm, lower serum lactate levels, higher blood pH, and a lower Sequential Organ Failure Assessment score. Indications for ECPR include young age, witnessed arrest with bystander cardiopulmonary resuscitation, an initial shockable rhythm, correctable causes such as a cardiac etiology, and no return of spontaneous circulation within 10–20 minutes of CCPR. ECPR is a complex intervention that requires a highly trained team, specialized equipment, and multidisciplinary support within a healthcare system, and it has the risk of several life-threatening complications. Therefore, physicians should carefully select patients for ECPR who can gain the most benefit, instead of applying ECPR indiscriminately.

Cardiovascular Magnetic Resonance Imaging of Inherited Heart Conditions

Imaging modalities are central to diagnosis and prognostication of confirmed or suspected inherited cardiomyopathies. The availability and use of cardiovascular magnetic resonance imaging (CMR) to supplement traditional modalities has increased substantially and has several advantages over traditional imaging techniques. CMR is unique in its ability to easily acquire images in any plane. Moreover, advances in CMR sequences have begun to enable characterisation of the myocardium without the need for invasive biopsy and has provided a major step forward in the understanding of inherited heart disease pathology and genotype-phenotype interactions. This review summarises the current role of CMR in inherited cardiomyopathies depending on their genotype and phenotype status, using arrhythmogenic right ventricular dysplasia/cardiomyopathy and hypertrophic cardiomyopathy as prototypical examples.