Extracorporeal Cardiopulmonary Resuscitation and Survival After Refractory Cardiac Arrest: Is ECPR Beneficial?

Mortality Predictors and Neurological Outcomes Following Extracorporeal Cardiopulmonary Resuscitation (eCPR): A Single-Center Retrospective Study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (eCPR) offers cardiorespiratory support to patients experiencing cardiac arrest. However, this technology is not yet considered a standard treatment, and the evidence on eCPR criteria and its association with survival and good neurological outcomes remains scarce. Therefore, we aimed to investigate the overall mortality and risk factors for mortality. Moreover, we provide a comparison of demographic, clinical, and laboratory characteristics of patients, including neurological outcomes and adverse events during support.

METHODS

This retrospective analysis included in-hospital and out-of-hospital cardiac arrest patients who received eCPR and were admitted between January 2008 and June 2022 at a tertiary and trauma one-level university hospital in Austria.

RESULTS

In total, 90 patients fulfilled inclusion criteria, 41 (46%) patients survived until intensive care unit discharge, and 39 (43%) survived until hospital discharge. The most common cause of cardiac arrest was myocardial infarction (42, 47%), and non-shockable initial rhythm was reported in 50 patients (56%). Of 33 survivors with documented outcomes, 30 had a good recovery as measured with Cerebral Performance Category score, 2 suffered severe disability, and 1 remained in a persistent vegetative state. Finally, multivariate analysis identified asystole as initial rhythm (HR 2.88, p = 0.049), prolonged CPR (HR 1.02, p = 0.043), and CPR on the weekend (HR 2.57, p = 0.032) as factors with a higher risk of mortality.

CONCLUSIONS

eCPR-related decision-making could be additionally supported by the comprehension of the reported risk factors for mortality and severe disability. Further studies are needed to elucidate the impact of peri-arrest variables on outcomes, aiming to improve patient selection.

Impact of mechanical circulatory support on out-of-hospital cardiac arrest outcomes stratified by vasoactive-inotropic score: A retrospective cohort study

Aims

To assess whether mechanical circulatory support (MCS), including intra-aortic balloon pump (IABP) or veno-arterial extracorporeal membrane oxygenation (ECMO), can help improve neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA).

Methods

This is a retrospective observational cohort study performed in China Medical University Hospital, Taichung, Taiwan. Adult patients with OHCA admitted between January 2015 and June 2023. Quantitative score of vasoactive-inotropic agents and qualitative interventions of MCS, including IABP and ECMO after OHCA. Multivariate regression evaluated the efficacy of each MCS approach in patients stratified by the vasoactive-inotropic score (VIS).

Results

A total of 334 patients were included and analyzed, 122 (36.5%) had favorable neurological outcomes and 215 (64.4%) survived ≥90 days. These patients were stratified by VIS: 0-25, 26-100, 101-250, and >250. In patients with a VIS > 100, ECMO with or without IABP ensured favorable neurological outcomes and survival after OHCA compared to non-MCS interventions (p < 0.001). For patients with a VIS ≤ 100, IABP alone was beneficial, with no significant outcome difference from non-MCS interventions (p > 0.05).

Conclusions

ECMO with or without IABP therapy may improve post-OHCA neurological outcomes and survival in patients with an expected VIS-24 h > 100 (e.g., epinephrine dose reaches 3 mg during CPR).

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.

The impact of on-site cardiac rhythm on mortality in patients supported with extracorporeal cardiopulmonary resuscitation: A retrospective cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used in patients with out-of-hospital or in-hospital cardiac arrest in whom conventional cardiopulmonary resuscitation remains unsuccessful. The aim of this study was to analyze the impact of initial cardiac rhythm-detected on-site of the cardiac arrest-on mortality.

METHODS

We performed a retrospective cohort study of patients who received ECPR in our tertiary care cardiac arrest center. Patients were divided into three groups depending on their cardiac rhythm: shockable rhythm, pulseless electrical activity, and asystole. The primary endpoint was mortality within the first 7 days after ECPR deployment. Secondary endpoints were mortality within 28 days and the impact of pre-ECPR potassium, serum lactate, pH, and pCO₂ on mortality. The association of the initial cardiac rhythm and the location of arrhythmia detection (patient monitored in hospital [category: monitored], not monitored but hospitalized [in-hospital], not monitored, not hospitalized [out-of hospital]) with the primary and secondary outcome was examined by means of univariable and multivariable logistic regression.

RESULTS

Sixty-five patients could be included in the final analysis. Thirty-two patients (49.2%, 95%CI 36.6%-61.9%) died within the first 7 days. In terms of 7-day-mortality patients differed in the initial cardiac rhythm (p = 0.040) and with respect to the location of arrhythmia detection (p = 0.002). Shockable cardiac rhythm (crude OR 0.21; 95%CI 0.03-0.98) and pulseless electrical activity (0.13; 0.02-0.61) as the initial rhythm on-site showed better odds for survival compared to asystole. However, this association did neither persist in adjusted analysis nor pairwise comparison.

DISCUSSION

The study could not demonstrate a better outcome with shockable rhythm after ECPR. More homogeneous and adequately powered cohorts are needed to better understand the impact of cardiac rhythm on patient outcomes after ECPR.