OBJECTIVES: After cardiac arrest, a key factor determining survival outcomes is low-flow duration. Our aims were to determine the relation of survival and low-flow duration of extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) and if these 2 therapies have different short-term survival curves in relation to low-flow duration. METHODS: We searched Embase, Medline, Web of Science and Google Scholar from inception up to April 2021. A linear mixed-effect model was used to describe the course of survival over time, based on study-specific and time-specific aggregated survival data. RESULTS: We included 42 observational studies reporting on 1689 ECPR and 375 751 CCPR procedures. Of the included studies, 25 included adults, 13 included children and 4 included both. In adults, survival curves decline rapidly over time (ECPR 37.2%, 29.8%, 23.8% and 19.1% versus CCPR-shockable 36.8%, 7.2%, 1.4% and 0.3% for 15, 30, 45 and 60 min low-flow, respectively). ECPR was associated with a statistically significant slower decline in survival than CCPR with initial shockable rhythms (CCPR-shockable). In children, survival curves decline rapidly over time (ECPR 43.6%, 41.7%, 39.8% and 38.0% versus CCPR-shockable 48.6%, 20.5%, 8.6% and 3.6% for 15, 30, 45 and 60 min low-flow, respectively). ECPR was associated with a statistically significant slower decline in survival than CCPR-shockable. CONCLUSIONS: The short-term survival of ECPR and CCPR-shockable patients both decline rapidly over time, in adults as well as in children. This decline of short-term survival in relation to low-flow duration in ECPR was slower than in conventional cardiopulmonary resuscitation. TRIAL REGISTRATION: Prospero: CRD42020212480, 2 October 2020.

Cardio Thoracic Surgery Department Heart and Vascular Centre Maastricht University Medical Centre Cardiovascular Research Institute Maastricht Maastricht Netherlands

Department of Adult Intensive Care Erasmus University Medical Center Rotterdam Netherlands

Department of Cardiology Erasmus University Medical Center Rotterdam Netherlands

Department of Cardiology Maasstad Hospital Rotterdam Netherlands

Department of Cardiovascular Medicine 2nd Faculty of Medicine Charles University Prague Prague Czech Republic

Department of Intensive Care Maasstad Hospital Rotterdam Netherlands

UOC Anestesia e Rianimazione 2 Cardiopolmonare Fondazione IRCC Policlinico San Matteo Pavia Italy

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World Health Organisation. 2020. https://www.who.int/ (1 February 2020, date last accessed).

Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Vaillancourt C. et al. Pre-arrest and intra-arrest prognostic factors associated with survival after in-hospital cardiac arrest: systematic review and meta-analysis. BMJ 2019;367:l6373. PubMed PMC

Patz T, Stelzig K, Pfeifer R, Pittl U, Thiele H, Busch HJ. et al. Age-associated outcomes after survived out-of-hospital cardiac arrest and subsequent target temperature management. Acta Anaesthesiol Scand 2019;63:1079–88. PubMed

Zhang Q, Qi Z, Liu B, Li C.. Predictors of survival and favorable neurological outcome in patients treated with targeted temperature management after cardiac arrest: a systematic review and meta-analysis. Heart Lung 2018;47:602–9. PubMed

Lee SH, Jung JS, Lee KH, Kim HJ, Son HS, Sun K.. Comparison of extracorporeal cardiopulmonary resuscitation with conventional cardiopulmonary resuscitation: s extracorporeal cardiopulmonary resuscitation beneficial? Korean J Thorac Cardiovasc Surg 2015;48:318–27. PubMed PMC

Yannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA. et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet 2020;396:1807–16. PubMed PMC

Ouweneel DM, Schotborgh JV, Limpens J, Sjauw KD, Engstrom AE, Lagrand WK. et al. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med 2016;42:1922–34. PubMed PMC

Twohig CJ, Singer B, Grier G, Finney SJ.. A systematic literature review and meta-analysis of the effectiveness of extracorporeal-CPR versus conventional-CPR for adult patients in cardiac arrest. J Intensive Care Soc 2019;20:347–57. PubMed PMC

Adnet F, Triba MN, Borron SW, Lapostolle F, Hubert H, Gueugniaud PY. et al. Cardiopulmonary resuscitation duration and survival in out-of-hospital cardiac arrest patients. Resuscitation 2017;111:74–81. PubMed

Martinell L, Nielsen N, Herlitz J, Karlsson T, Horn J, Wise MP. et al. Early predictors of poor outcome after out-of-hospital cardiac arrest. Crit Care 2017;21:96. PubMed PMC

Wengenmayer T, Rombach S, Ramshorn F, Biever P, Bode C, Duerschmied D. et al. Influence of low-flow time on survival after extracorporeal cardiopulmonary resuscitation (eCPR). Crit Care 2017;21:157. PubMed PMC

Blumenstein J, Leick J, Liebetrau C, Kempfert J, Gaede L, Groß S. et al. Extracorporeal life support in cardiovascular patients with observed refractory in-hospital cardiac arrest is associated with favourable short and long-term outcomes: a propensity-matched analysis. Eur Heart J Acute Cardiovasc Care 2016;5:13–22. PubMed

Choi DS, Kim T, Ro YS, Ahn KO, Lee EJ, Hwang SS. et al. Extracorporeal life support and survival after out-of-hospital cardiac arrest in a nationwide registry: a propensity score-matched analysis. Resuscitation 2016;99:26–32. PubMed

Kim SJ, Jung JS, Park JH, Park JS, Hong YS, Lee SW.. An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study. Crit Care 2014;18:535. PubMed PMC

Lasa JJ, Rogers RS, Localio R, Shults J, Raymond T, Gaies M. et al. Extracorporeal Cardiopulmonary Resuscitation (E-CPR) during pediatric in-hospital cardiopulmonary arrest is associated with improved survival to discharge: a report from the American Heart Association's Get with the Guidelines-Resuscitation (GWTG-R) Registry. Circulation 2016;133:165–76. PubMed PMC

Maekawa K, Tanno K, Hase M, Mori K, Asai Y.. Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis. Crit Care Med 2013;41:1186–96. PubMed

Patricio D, Peluso L, Brasseur A, Lheureux O, Belliato M, Vincent JL. et al. Comparison of extracorporeal and conventional cardiopulmonary resuscitation: a retrospective propensity score matched study. Crit Care 2019;23:27. PubMed PMC

Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. PubMed PMC

Bembea MM, Ng DK, Rizkalla N, Rycus P, Lasa JJ, Dalton H. et al.; American Heart Association’s Get With The Guidelines—Resuscitation Investigators. Outcomes after extracorporeal cardiopulmonary resuscitation of pediatric in-hospital cardiac arrest: a report from the get with the guidelines-resuscitation and the extracorporeal life support organization registries. Crit Care Med 2019;47:e278–85. PubMed

Chen CT, Chiu PC, Tang CY, Lin YY, Lee YT, How CK. et al. Prognostic factors for survival outcome after in-hospital cardiac arrest: an observational study of the oriental population in Taiwan. J Chin Med Assoc 2016;79:11–6. PubMed

Chen YS, Lin JW, Yu HY, Ko WJ, Jerng JS, Chang WT. et al. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet 2008;372:554–61. PubMed

Chou TH, Fang CC, Yen ZS, Lee CC, Chen YS, Ko WJ. et al. An observational study of extracorporeal CPR for in-hospital cardiac arrest secondary to myocardial infarction. Emerg Med J 2014;31:441–7. PubMed

Dumot JA, Burval DJ, Sprung J, Waters JH, Mraovic B, Karafa MT. et al. Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of "limited" resuscitations. Arch Intern Med 2001;161:1751–8. PubMed

Ferguson RP, Phelan T, Haddad T, Hinduja A, Dubin NH.. Survival after in-hospital cardiopulmonary resuscitation. South Med J 2008;101:1007–11. PubMed

Goldberger ZD, Chan PS, Berg RA, Kronick SL, Cooke CR, Lu M. et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet 2012;380:1473–81. PubMed PMC

Goto Y, Funada A, Goto Y.. Duration of prehospital cardiopulmonary resuscitation and favorable neurological outcomes for pediatric out-of-hospital cardiac arrests: a nationwide, population-based cohort study. Circulation 2016;134:2046–59. PubMed

Grunau B, Puyat J, Wong H, Scheuermeyer FX, Reynolds JC, Kawano T. et al. Gains of continuing resuscitation in refractory out-of-hospital cardiac arrest: a model-based analysis to identify deaths due to intra-arrest prognostication. Prehosp Emerg Care 2018;22:198–207. PubMed

Hendrick JM, Pijls NH, van der Werf T, Crul JF.. Cardiopulmonary resuscitation on the general ward: no category of patients should be excluded in advance. Resuscitation 1990;20:163–71. PubMed

Kalloghlian AK, Matthews NT, Khan BA.. Outcome of in-hospital pediatric cardiac arrest. Ann Saudi Med 1998;18:208–11. PubMed

Lopez-Herce J, Del Castillo J, Matamoros M, Canadas S, Rodriguez-Calvo A, Cecchetti C. et al.; Iberoamerican Pediatric Cardiac Arrest Study Network RIBEPCI. Factors associated with mortality in pediatric in-hospital cardiac arrest: a prospective multicenter multinational observational study. Intensive Care Med 2013;39:309–18. PubMed

Lopez-Herce J, Garcia C, Dominguez P, Carrillo A, Rodriguez-Nunez A, Calvo C. et al. Characteristics and outcome of cardiorespiratory arrest in children. Resuscitation 2004;63:311–20. PubMed

Matos RI, Watson RS, Nadkarni VM, Huang HH, Berg RA, Meaney PA. et al. Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests. Circulation 2013;127:442–51. PubMed

Morris MC, Wernovsky G, Nadkarni VM.. Survival outcomes after extracorporeal cardiopulmonary resuscitation instituted during active chest compressions following refractory in-hospital pediatric cardiac arrest. Pediatr Crit Care Med 2004;5:440–6. PubMed

Nagao K, Nonogi H, Yonemoto N, Gaieski DF, Ito N, Takayama M. et al. Duration of Prehospital resuscitation efforts after out-of-hospital cardiac arrest. Circulation 2016;133:1386–96. PubMed

Otani T, Sawano H, Natsukawa T, Nakashima T, Oku H, Gon C. et al. Low-flow time is associated with a favorable neurological outcome in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation. J Crit Care 2018;48:15–20. PubMed

Pionkowski RS, Thompson BM, Gruchow HW, Aprahamian C, Darin JC.. Resuscitation time in ventricular fibrillation–a prognostic indicator. Ann Emerg Med 1983;12:733–8. PubMed

Rathore V, Bansal A, Singhi SC, Singhi P, Muralidharan J.. Survival and neurological outcome following in-hospital paediatric cardiopulmonary resuscitation in North India. Paediatr Int Child Health 2016;36:141–7. PubMed

Reynolds JC, Grunau BE, Rittenberger JC, Sawyer KN, Kurz MC, Callaway CW.. Association between duration of resuscitation and favorable outcome after out-of-hospital cardiac arrest: implications for prolonging or terminating resuscitation. Circulation 2016;134:2084–94. PubMed PMC

Rosenberg M, Wang C, Hoffman-Wilde S, Hickam D.. Results of cardiopulmonary resuscitation. Failure to predict survival in two community hospitals. Arch Intern Med 1993;153:1370–5. PubMed

Shinn SH, Lee YT, Sung K, Min S, Kim WS, Park PW. et al. Efficacy of emergent percutaneous cardiopulmonary support in cardiac or respiratory failure: fight or flight? Interact CardioVasc Thorac Surg 2009;9:269–73. PubMed

Sivarajan VB, Best D, Brizard CP, Shekerdemian LS, d'Udekem Y, Butt W.. Duration of resuscitation prior to rescue extracorporeal membrane oxygenation impacts outcome in children with heart disease. Intensive Care Med 2011;37:853–60. PubMed

Wang CH, Chou NK, Becker LB, Lin JW, Yu HY, Chi NH. et al. Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest—a comparison with that for extracorporeal rescue for in-hospital cardiac arrest. Resuscitation 2014;85:1219–24. PubMed

Younger JG, Schreiner RJ, Swaniker F, Hirschl RB, Chapman RA, Bartlett RH.. Extracorporeal resuscitation of cardiac arrest. Acad Emerg Med 1999;6:700–7. PubMed

Yukawa T, Kashiura M, Sugiyama K, Tanabe T, Hamabe Y.. Neurological outcomes and duration from cardiac arrest to the initiation of extracorporeal membrane oxygenation in patients with out-of-hospital cardiac arrest: a retrospective study. Scand J Trauma Resusc Emerg Med 2017;25:95. PubMed PMC

Fjølner J, Greisen J, Jørgensen MRS, Terkelsen CJ, Ilkjaer LB, Hansen TM. et al. Extracorporeal cardiopulmonary resuscitation after out-of-hospital cardiac arrest in a Danish health region. Acta Anaesthesiol Scand 2017;61:176–85. PubMed

Ganesan RG, Das S, Parameswara N, Biswal N, Pabhu A.. Survival after in-hospital cardiac arrest among paediatric patients—a descriptive study. J Clin Diagn Res 2018;12:SC04–9.

Haneya A, Philipp A, Diez C, Schopka S, Bein T, Zimmermann M. et al. A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest. Resuscitation 2012;83:1331–7. PubMed

Valentin A, Karnik R, Donath P, Winkler WB, Slany J.. Outcome of cardiopulmonary resuscitation in hospitalized patients. Resuscitation 1995;30:217–21.

Innes PA, Summers CA, Boyd IM, Molyneux EM.. Audit of pediatric cardiopulmonary-resuscitation. Arch Dis Child 1993;68:487–91. PubMed PMC

Park JH, Song KJ, Shin SD, Ro YS, Hong KJ.. Time from arrest to extracorporeal cardiopulmonary resuscitation and survival after out-of-hospital cardiac arrest. Emerg Med Australas 2019;31:1073–81. PubMed

Bartos JA, Grunau B, Carlson C, Duval S, Ripeckyj A, Kalra R. et al. Improved survival with extracorporeal cardiopulmonary resuscitation despite progressive metabolic derangement associated with prolonged resuscitation. Circulation 2020;142(11):877–886. PubMed PMC

Murakami N, Kokubu N, Nagano N, Nishida J, Nishikawa R, Nakata J. et al. Prognostic impact of no-flow time on 30-day neurological outcomes in patients with out-of-hospital cardiac arrest who received extracorporeal cardiopulmonary resuscitation. Circ J 2020;84:1097–104. PubMed

Pound G, Jones D, Eastwood GM, Paul E, Hodgson CL; ANZ-CODE Investigators. Survival and functional outcome at hospital discharge following in-hospital cardiac arrest (IHCA): a prospective multicentre observational study. Resuscitation 2020;155:48–54. PubMed

Kramer P, Mommsen A, Miera O, Photiadis J, Berger F, Schmitt KRL.. Survival and mid-term neurologic outcome after extracorporeal cardiopulmonary resuscitation in children. Pediatr Crit Care Med 2020;21:e316–24. PubMed

Mandigers L, den Uil CA, Bunge JJH, Gommers D, Dos Reis Miranda D.. Initial arterial pCO2 and its course in the first hours of extracorporeal cardiopulmonary resuscitation show no association with recovery of consciousness in humans: a single-centre retrospective study. Membranes (Basel) 2021;11:208. PubMed PMC

Meert KL, Guerguerian AM, Barbaro R, Slomine BS, Christensen JR, Berger J. et al.; Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) Trial Investigators. Extracorporeal cardiopulmonary resuscitation: one-year survival and neurobehavioral outcome among infants and children with in-hospital cardiac arrest. Crit Care Med 2019;47:393–402. PubMed PMC

Siao FY, Chiu CW, Chiu CC, Chang YJ, Chen YC, Chen YL. et al. Can we predict patient outcome before extracorporeal membrane oxygenation for refractory cardiac arrest? Scand J Trauma Resusc Emerg Med 2020;28:58. PubMed PMC

Chen Z, Liu C, Huang J, Zeng P, Lin J, Zhu R. et al. Clinical efficacy of extracorporeal cardiopulmonary resuscitation for adults with cardiac arrest: meta-analysis with trial sequential analysis. Biomed Res Int 2019;2019:6414673. PubMed PMC

Holmberg MJ, Geri G, Wiberg S, Guerguerian AM, Donnino MW, Nolan JP. et al.; International Liaison Committee on Resuscitation’s (ILCOR) Advanced Life Support and Pediatric Task Forces. Extracorporeal cardiopulmonary resuscitation for cardiac arrest: a systematic review. Resuscitation 2018;131:91–100. PubMed PMC

Funada A, Goto Y, Tada H, Teramoto R, Shimojima M, Hayashi K. et al. Duration of cardiopulmonary resuscitation in patients without prehospital return of spontaneous circulation after out-of-hospital cardiac arrest: Results from a severity stratification analysis. Resuscitation 2018;124:69–75. PubMed

Gregers E, Kjærgaard J, Lippert F, Thomsen JH, Køber L, Wanscher M. et al. Refractory out-of-hospital cardiac arrest with ongoing cardiopulmonary resuscitation at hospital arrival—survival and neurological outcome without extracorporeal cardiopulmonary resuscitation. Crit Care 2018;22:242. PubMed PMC

Lamhaut L, Hutin A, Puymirat E, Jouan J, Raphalen JH, Jouffroy R. et al. A pre-hospital extracorporeal cardio pulmonary resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: an observational study and propensity analysis. Resuscitation 2017;117:109–17. PubMed

Singer B, Reynolds JC, Davies GE, Wrigley F, Whitbread M, Faulkner M. et al.; International ECMO Network (ECMONet). Sub30: protocol for the Sub30 feasibility study of a pre-hospital Extracorporeal membrane oxygenation (ECMO) capable advanced resuscitation team at achieving blood flow within 30 min in patients with refractory out-of-hospital cardiac arrest. Resusc Plus 2020;4:100029. PubMed PMC

DdR M. ON-SCENE Initiation of Extracorporeal CardioPulmonary Resuscitation During Refractory Out-of-Hospital Cardiac Arrest (ON-SCENE). Clinicaltrials.gov 2020. https://clinicaltrials.gov/ct2/show/NCT04620070 (1 February 2020, date last accessed).

Current trends in the management of out of hospital cardiac arrest (OHCA)

Extracorporeal cardiopulmonary resuscitation for refractory OHCA: lessons from three randomized controlled trials-the trialists' view