Refractory Ventricle Arrhythmias Alternating with Pulseless Electrical Activity in a Young Woman Rescued by Extracorporeal Cardiopulmonary Resuscitation

Analysis of factors associated with favorable neurological outcomes in patients with initial PEA who underwent ECPR - A secondary analysis of the SAVE-J II study

PURPOSE

This study aimed to investigate the factors of favorable neurological outcomes in patients with initial pulseless electrical activity (PEA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

The study analyzed data from the SAVE-J II registry, a retrospective multicenter registry involving 36 participating institutions in Japan. Patients with initial PEA were included.

RESULTS

Overall proportion of patients with favorable neurological outcomes and survival rate at hospital discharge were 8.2 % and 16.9 %, respectively. Multivariate analysis revealed that no cardiac rhythm conversion to asystole, signs of life or pupil diameter, and transient return of spontaneous circulation were significantly associated with favorable neurological outcomes. Among the cause of cardiac arrest, patients with acute coronary syndrome and pulmonary embolism had higher proportions of favorable neurological outcomes (9.7 % and 19.3 %), whereas no patients with acute aortic disease or primary cerebral disease survived. The application of strict criteria for PEA using classification and regression tree analysis resulted in favorable neurological outcomes in 32.7 % of the patients.

CONCLUSIONS

This study provides an overview of patients with PEA who underwent ECPR. Since several factors are associated with favorable neurological outcomes, patients with PEA may be candidates for ECPR if these factors are met.

A novel extracorporeal cardiopulmonary resuscitation strategy using a hybrid emergency room for patients with pulseless electrical activity

BACKGROUND

Whether extracorporeal cardiopulmonary resuscitation (ECPR) is indicated for patients with pulseless electrical activity (PEA) remains unclear. Pulmonary embolism with PEA is a good candidate for ECPR; however, PEA can sometimes include an aortic disease and intracranial haemorrhage, with extremely poor neurological outcomes, and can thus not be used as a suitable candidate. We began employing an ECPR strategy that utilised a hybrid emergency room (ER) to perform computed tomography (CT) before extracorporeal membrane oxygenation (ECMO) induction from January 2020. Therefore, the present study aimed to evaluate the effectiveness of this ECPR strategy.

METHODS

Medical records of patients who transferred to our hybrid ER and required ECPR for PEA between January 2020 and November 2021 were reviewed.

RESULTS

Twelve consecutive patients (median age, 67 [range, 57-73] years) with PEA requiring ECPR were identified in our hybrid ER. Among these patients, nine were diagnosed using an initial CT scan (intracranial haemorrhage (3); cardiac tamponade due to aortic dissection (3); aortic rupture (2); and cardiac rupture (1)), and unnecessary ECMO was avoided. The remaining three patients underwent ECPR, and two of them survived with favourable neurological outcomes. Patients not indicated for ECPR were excluded before ECMO induction.

CONCLUSION

Our ECPR strategy that involved the utilisation of a hybrid ER may be useful for the exclusion of patients with PEA not indicated for ECPR and decision making.

Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest in Adult Patients

Extracorporeal cardiopulmonary resuscitation (ECPR) followed by targeted temperature management has been demonstrated to significantly improve the outcomes of out-of-hospital cardiac arrest (OHCA) in adult patients. Although recent narrative and systematic reviews on extracorporeal life support in the emergency department are available in the literature, they are focused on the efficacy of ECPR, and no comprehensively summarized review on ECPR for OHCA in adult patients is available. In this review, we aimed to clarify the prevalence, pathophysiology, predictors, management, and details of the complications of ECPR for OHCA, all of which have not been reviewed in previous literature, with the aim of facilitating understanding among acute care physicians. The leading countries in the field of ECPR are those in East Asia followed by those in Europe and the United States. ECPR may reduce the risks of reperfusion injury and deterioration to secondary brain injury. Unlike conventional cardiopulmonary resuscitation, however, no clear prognostic markers have been identified for ECPR for OHCA. Bleeding was identified as the most common complication of ECPR in patients with OHCA. Future studies should combine ECPR with intra-aortic balloon pump, extracorporeal membrane oxygenation flow, target blood pressure, and seizure management in ECPR.