Long-term neurologically intact survival after extracorporeal cardiopulmonary resuscitation for in-hospital or out-of-hospital cardiac arrest: A systematic review and meta-analysis

Extracorporeal Versus Conventional Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest: A Propensity Score Matching Cohort Study

OBJECTIVE

Comparing the effects of extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) on outcomes in patients with in-hospital cardiac arrest (IHCA) in China. The benefits of ECPR over CCPR in patients with IHCA remain controversial.

DESIGN

This article analyzed data from the BASeline Investigation of In-hospital Cardiac Arrest (BASIC-IHCA) study, which consecutively enrolled patients with IHCA from July 1, 2019, to December 31, 2020. Patients who received ECPR were selected as the case group and matched with patients who received CCPR as the control group by propensity score at a ratio of 1:4. A parallel questionnaire survey of participating hospitals was conducted, to collect data on ECPR cases from January 1, 2021 to November 30, 2021. The primary outcome was survival to discharge or 30-day survival.

SETTING

We included 39 hospitals across 31 provinces in China.

PATIENTS

Patients receiving cardiopulmonary resuscitation and without contraindications to ECPR were selected from the BASIC-IHCA database. Patients older than 75 years, not witnessed, or with cardiopulmonary resuscitation duration less than 10 min were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 4853 patients met the inclusion criteria before matching, with 34 undergoing ECPR (median age, 56.5 yr; 67.65% male) and 4819 underwent CCPR (median age, 59 yr; 64.52% male). There were 132 patients receiving CCPR and 33 patients receiving ECPR who were eventually matched. The ECPR group had significantly higher survival rates at discharge or 30-day survival (21.21% vs. 7.58%, p = 0.048). The ECPR group had significantly lower mortality rates (hazard ratio 0.57; 95% CI, 0.38-0.91) than the CCPR group at discharge or 30 days. Besides the BASIC-IHCA study, the volume of ECPR implementations and the survival rate of patients with ECPR (29.4% vs. 10.4%. p = 0.004) in participating hospitals significantly improved.

CONCLUSIONS

ECPR may be beneficial compared with CCPR for patient survival after IHCA and should be considered for eligible patients with IHCA.

[Open questions with respect to extracorporeal circulatory support 2024]

The use of extracorporeal circulatory support, both for cardiogenic shock and during resuscitation, still presents many unanswered questions. The inclusion and exclusion criteria for such a resource-intensive treatment must be clearly defined, considering that these criteria are directly associated with the type and location of treatment. For example, it is worth questioning the viability of an extracorporeal resuscitation program in areas where it is impossible to achieve low-flow times under 60 min due to local limitations. Additionally, the best approach for further treatment, including whether it is necessary to regularly relieve the left ventricle, must be explored. To find answers to some of these questions, large-scale, multicenter, randomized studies and registers must be performed. Until then this treatment must be carefully considered before use.

Extracorporeal membrane oxygenation technology for adults: an evidence mapping based on systematic reviews

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is a cutting-edge life-support measure for patients with severe cardiac and pulmonary illnesses. Although there are several systematic reviews (SRs) about ECMO, it remains to be seen how quality they are and how efficacy and safe the information about ECMO they describe is in these SRs. Therefore, performing an overview of available SRs concerning ECMO is crucial.

METHODS

We searched four electronic databases from inception to January 2023 to identify SRs with or without meta-analyses. The Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) tool, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were used to assess the methodological quality, and evidence quality for SRs, respectively. A bubble plot was used to visually display clinical topics, literature size, number of SRs, evidence quality, and an overall estimate of efficacy.

RESULTS

A total of 17 SRs met eligibility criteria, which were combined into 9 different clinical topics. The methodological quality of the included SRs in this mapping was "Critically low" to "Moderate". One of the SRs was high-quality evidence, three on moderate, three on low, and two on very low-quality evidence. The most prevalent study used to evaluate ECMO technology was observational or cohort study with frequently small sample sizes. ECMO has been proven beneficial for severe ARDS and ALI due to the H1N1 influenza infection. For ARDS, ALF or ACLF, and cardiac arrest were concluded to be probably beneficial. For dependent ARDS, ARF, ARF due to the H1N1 influenza pandemic, and cardiac arrest of cardiac origin came to an inconclusive conclusion. There was no evidence for a harmful association between ECMO and the range of clinical topics.

CONCLUSIONS

There is limited available evidence for ECMO that large sample, multi-center, and multinational RCTs are needed. Most clinical topics are reported as beneficial or probably beneficial of SRs for ECMO. Evidence mapping is a valuable and reliable methodology to identify and present the existing evidence about therapeutic interventions.

Prophylactic distal perfusion catheter and survival in patients with out-of-hospital cardiac arrest: Secondary analysis of the SAVE-J II study

PURPOSE

The effect of a prophylactic distal perfusion catheter (DPC) after extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) remains unclear. Therefore, we aimed to clarify the association between prophylactic DPC and prognosis in patients with OHCA undergoing ECPR.

MATERIALS AND METHODS

A secondary analysis of the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan (SAVE-J II) database was performed to compare groups of patients with and without prophylactic DPCs. A multivariate analysis of survival at discharge was performed using factors that were significant in the two-arm comparison.

RESULTS

A total of 2044 patients were included in the analysis after excluding those who met the exclusion criteria. Survival at discharge was observed in 548 (26.9%) patients. In total, 100 (4.9%) patients developed limb ischemia, among whom 14 (0.7%) required therapeutic intervention. Multivariate analysis showed that prophylactic DPC did not result in a significant difference in survival at discharge (odds ratio: 0.898 [0.652-1.236], p = 0.509).

CONCLUSIONS

The implementation of prophylactic DPC after ECPR for patients with OHCA may not contribute to survival at discharge.

Benefits, key protocol components, and considerations for successful implementation of extracorporeal cardiopulmonary resuscitation: a review of the recent literature

The application of venoarterial extracorporeal membrane oxygenation (ECMO) in patients unresponsive to conventional cardiopulmonary resuscitation (CPR) has significantly increased in recent years. To date, three published randomized trials have investigated the use of extracorporeal CPR (ECPR) in adults with refractory out-of-hospital cardiac arrest. Although these trials reported inconsistent results, they suggest that ECPR may have a significant survival benefit over conventional CPR in selected patients only when performed with strict protocol adherence in experienced emergency medical services-hospital systems. Several studies suggest that identifying suitable ECPR candidates and reducing the time from cardiac arrest to ECMO initiation are key to successful outcomes. Prehospital ECPR or the rendezvous approach may allow more patients to receive ECPR within acceptable timeframes than ECPR initiation on arrival at a capable hospital. ECPR is only one part of the system of care for resuscitation of cardiac arrest victims. Optimizing the chain of survival is critical to improving outcomes of patients receiving ECPR. Further studies are needed to find the optimal strategy for the use of ECPR.

Predicting neurological outcome after cardiac arrest by combining computational parameters extracted from standard and deviant responses from auditory evoked potentials

Background

Despite multimodal assessment (clinical examination, biology, brain MRI, electroencephalography, somatosensory evoked potentials, mismatch negativity at auditory evoked potentials), coma prognostic evaluation remains challenging.

Methods

We present here a method to predict the return to consciousness and good neurological outcome based on classification of auditory evoked potentials obtained during an oddball paradigm. Data from event-related potentials (ERPs) were recorded noninvasively using four surface electroencephalography (EEG) electrodes in a cohort of 29 post-cardiac arrest comatose patients (between day 3 and day 6 following admission). We extracted retrospectively several EEG features (standard deviation and similarity for standard auditory stimulations and number of extrema and oscillations for deviant auditory stimulations) from the time responses in a window of few hundreds of milliseconds. The responses to the standard and the deviant auditory stimulations were thus considered independently. By combining these features, based on machine learning, we built a two-dimensional map to evaluate possible group clustering.

Results

Analysis in two-dimensions of the present data revealed two separated clusters of patients with good versus bad neurological outcome. When favoring the highest specificity of our mathematical algorithms (0.91), we found a sensitivity of 0.83 and an accuracy of 0.90, maintained when calculation was performed using data from only one central electrode. Using Gaussian, K-neighborhood and SVM classifiers, we could predict the neurological outcome of post-anoxic comatose patients, the validity of the method being tested by a cross-validation procedure. Moreover, the same results were obtained with one single electrode (Cz).

Conclusion

statistics of standard and deviant responses considered separately provide complementary and confirmatory predictions of the outcome of anoxic comatose patients, better assessed when combining these features on a two-dimensional statistical map. The benefit of this method compared to classical EEG and ERP predictors should be tested in a large prospective cohort. If validated, this method could provide an alternative tool to intensivists, to better evaluate neurological outcome and improve patient management, without neurophysiologist assistance.

Outcomes of Patients With in- and out-of-hospital Cardiac Arrest on Extracorporeal Cardiopulmonary Resuscitation: A Single-center Retrospective Cohort Study

Extracorporeal membrane oxygenation (ECMO) support has been suggested to improve the survival rate in patients with refractory in- and out-of-hospital cardiac arrest (IHCA and OHCA). Several factors predict outcome in these patients, including initial heart rhythm and low-flow time. Literature shows variable survival rates among patients who received extracorporeal cardiopulmonary resuscitation (EPCR). The objective of this study is to analyze the outcomes (survival rate as well as neurological and disability outcomes) of patients treated with ECPR following refractory OHCA and IHCA. This single-center, retrospective cohort study was conducted on patients with refractory cardiac arrest treated with ECPR between February 2016 and March 2020. The primary outcomes were 24-hour, hospital discharge and 1-year survival after CA and the secondary endpoints were neurological and disability outcomes. Forty-eight patients were included in the analysis. 11/48 patients are In Hospital Cardiac Arrest (IHCA) and 37/48 patients are Out of Hospital Cardiac Arrest (OHCA). Time from collapse to CPR for 79.2% of the patients was less than 5 minutes. The median CPR duration and collapse to ECMO were 40 and 45 minutes, respectively. The rate of survival was significantly higher in patient who presented with initial shockable rhythm (P = 0.006) and to whom targeted temperature management (TTM) post cardiac arrest was applied (P = 0.048). This first descriptive study about ECPR in the middle east region shows that 20.8% of ECPR patients survived until hospital discharge. Our analysis revealed that initial shockable rhythm and TTM are most important prognostic factors that predicts favorable neurological survival.

Emergency department initiated resuscitative endovascular balloon occlusion of the aorta (REBOA) for out-of-hospital cardiac arrest is feasible and associated with improvements in end-tidal carbon dioxide

Objectives

Out-of-hospital cardiac arrest (OHCA) claims the lives of approximately 350,000 people in the United States each year. Resuscitative endovascular balloon occlusion of the aorta (REBOA) when used as an adjunct to advanced cardiac life support may improve cardio-cerebral perfusion. Our primary research objective was to determine the feasibility of emergency department (ED)-initiated REBOA for OHCA patients in an academic urban ED.

Methods

This was a single-center, single-arm, early feasibility trial that used REBOA as an adjunct to advanced cardiac life support (ACLS) in OHCA. Subjects under 80 years with witnessed OHCA and who received cardiopulmonary rescuitation (CPR) within 6 minutes were eligible.

Results

Five patients were enrolled between February 2020 and April 2021. The procedure was successful in all patients and 4 of 5 (80%) patients had transient return of spontaneous circulation (ROSC) after aortic occlusion. Unfortunately, all patients re-arrested soon after intra-aortic balloon deflation and none survived to hospital admission. At 30 seconds post-aortic occlusion, investigators noted a statistically significant increase in end tidal carbon dioxide of 26% (95% confidence interval, 10%, 44%).

Conclusion

Initiating REBOA for OHCA patients in an academic urban ED setting is feasible. Aortic occlusion during chest compressions is temporally associated with improvements in end tidal carbon dioxide 30 seconds after aortic occlusion. Four of 5 patients achieved ROSC after aortic occlusion; however, deflation of the intra-aortic balloon quickly led to re-arrest and death in all patients. Future research should focus on the utilization of partial-REBOA to prevent re-arrest after ROSC, as well as the optimal way to incorporate this technique with other endovascular reperfusion strategies.

Survival and neurological outcome after out-of-hospital cardiac arrest treated with and without mechanical circulatory support

Aim

The aim of this study was to describe the survival and neurological outcome in patients with OHCA treated with and without mechanical circulatory support (MCS).

Methods

This was a retrospective observational cohort study on patients with OHCA admitted to Aarhus University Hospital, Denmark, between January 2015 and December 2019. Kaplan-Meier estimates were used to evaluate 30-day and 30–180-day survival. Cox regression analysis was used to assess the association between covariates and one-year mortality.

Results

Among 1,015 patients admitted, 698 achieved return of spontaneous circulation (ROSC) before admission, 101 patients with refractory OHCA received mechanical circulatory support (MCS) and the remaining 216 patients with refractory OHCA did not receive MCS treatment. Survival to hospital discharge was 47% (478/1015). Good neurological outcome defined as Cerebral Performance Categories 1–2 were seen among 92% (438/478) of the patients discharged from hospital. Median low-flow was 15 [8–22] minutes in the ROSC group and 105 [94–123] minutes in the MCS group. Mortality rates were high within the first 30 days, however; 30–180-day survival in patients discharged remained constant over time in both patients with ROSC on admission and patients admitted with MCS. Advanced age > 70 years (hazard ratio (HR) 1.98, 95% confidence interval (CI) 1.11–3.49), pulseless electrical activity (HR 2.39, 95% CI 1.25–4.60) and asystole HR 2.70, 95% CI 1.25–5.95) as initial rhythms were associated with one-year mortality in patients with ROSC.

Conclusions

Short-term survival rates were high among patients with ROSC and patients receiving MCS. Among patients who survived to day 30, landmark analyses showed comparable 180-day survival in the two groups despite long low-flow times in the MCS group. Advanced age and initial non-shockable rhythms were independent predictors of one-year mortality in patients with ROSC on admission.

Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest: a scoping review

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging concept in cardiac arrest and cardiopulmonary resuscitation. Recent research has documented a significant improvement in favorable outcomes, notable survival to discharge, and neurologically intact survival.

OBJECTIVES

The present study undertakes a scoping review to summarize the available evidence by assessing the use of ECPR, compared with no ECPR or the standard of care, for adult patients who sustain cardiac arrest in any setting, in studies which record survival and neurologic outcomes.

METHODS

This review followed the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. Four online databases were used to identify papers published from database inception to July 12, 2020. We selected 23 observational studies from Asia, Europe, and North America that used survival to discharge or neurologically intact survival as a primary or secondary endpoint variable in patients with cardiac arrest refractory to standard treatment.

RESULTS

Twenty-three observational studies were included in the review. Eleven studies were of out-of-hospital cardiac arrest, 7 studies were of in-hospital cardiac arrest, and 5 studies included mixed populations. Ten studies reported long-term favorable neurological outcomes (ie, Cerebral Performance Category score of 1 - 2 at 3 months [n = 3], 6 months [n = 3], and 1 year [n = 4]), of which only 4 had statistical significance at 5% significance levels. Current knowledge is mostly drawn from single-center observations, with most of the evidence coming from case series and cohort studies, hence is prone to publication bias. No randomized control trials were included.

CONCLUSIONS

This scoping review highlights the need for high-quality studies to increase the level of evidence and reduce knowledge gaps to change the paradigm of care for patients with shock-refractory cardiac arrest.