Extracorporeal cardiopulmonary resuscitation is a promising treatment for refractory out-of-hospital cardiac arrest. Three recent randomized trials (ARREST trial, Prague OHCA study, and INCEPTION trial) that addressed the clinical benefit of extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest yielded seemingly diverging results. The evidence for extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest, derived from three recent randomized controlled trials, is not contradictory but rather complementary. Excellent results can be achieved with a very high level of dedication, provided that strict selection criteria are applied. However, pragmatic implementation of extracorporeal cardiopulmonary resuscitation does not necessarily lead to improved outcome of refractory out-of-hospital cardiac arrest. Centres that are performing extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest or aspire to do so should critically evaluate whether they are able to meet the pre-requisites that are needed to conduct an effective extracorporeal cardiopulmonary resuscitation programme.

2nd Department of Medicine Department of Cardiovascular Medicine 1st Medical School General University Hospital and Charles University Prague U Nemocnice 2 Prague Czech Republic

Cardiovascular Research Institute Maastricht Maastricht University Maastricht The Netherlands

Center for Resuscitation Medicine University of Minnesota Medical School Minneapolis MN USA

Department of Anesthesia and Pain Medicine Maastricht University Medical Center Maastricht The Netherlands

Department of Cardiology Maastricht University Medical Center Maastricht The Netherlands

Department of Cardiothoracic Surgery Maastricht University Medical Center Maastricht The Netherlands

Department of Intensive Care Medicine Maastricht University Medical Center Maastricht The Netherlands

School of Nutrition and Translational Research in Metabolism Maastricht University Maastricht The Netherlands

Zobrazit více v PubMed

Downing J, Al Falasi R, Cardona S, Fairchild M, Lowie B, Chan C, et al. . How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis. Am J Emerg Med 2022;51:127–138. PubMed

Inoue A, Hifumi T, Sakamoto T, Kuroda Y. Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest in adult patients. J Am Heart Assoc 2020;9:e015291. PubMed PMC

Inoue A, Hifumi T, Sakamoto T, Okamoto H, Kunikata J, Yokoi H, et al. . Extracorporeal cardiopulmonary resuscitation in adult patients with out-of-hospital cardiac arrest: a retrospective large cohort multicenter study in Japan. Crit Care 2022;26:129. PubMed PMC

Scquizzato T, Bonaccorso A, Consonni M, Scandroglio AM, Swol J, Landoni G, et al. . Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of randomized and propensity score-matched studies. Artif Organs 2022;46:755–762. PubMed PMC

Belohlavek J, Kucera K, Jarkovsky J, Franek O, Pokorna M, Danda J, et al. . Hyperinvasive approach to out-of hospital cardiac arrest using mechanical chest compression device, prehospital intraarrest cooling, extracorporeal life support and early invasive assessment compared to standard of care. A randomized parallel groups comparative study proposal. “Prague OHCA study”. J Transl Med 2012;10:163. 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;396:1807–1816. PubMed PMC

Hsu CH, Meurer WJ, Domeier R, Fowler J, Whitmore SP, Bassin BS, et al. . Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest (EROCA): results of a randomized feasibility trial of expedited out-of-hospital transport. Ann Emerg Med 2021;78:92–101. PubMed PMC

NCT04620070 . Initiation of Extracorporeal CardioPulmonary Resuscitation During Refractory Out-of-Hospital Cardiac Arrest (ON-SCENE). https://clinicaltrials.gov/ct2/show/NCT04620070(22nd September 2022).

NCT01605409 . Emergency Cardiopulmonary Bypass for Cardiac Arrest (ECPB4OHCA).

Belohlavek J, Smalcova J, Rob D, Franek O, Smid O, Pokorna M, et al. . Effect of intra-arrest transport, extracorporeal cardiopulmonary resuscitation, and immediate invasive assessment and treatment on functional neurologic outcome in refractory out-of-hospital cardiac arrest: a randomized clinical trial. JAMA 2022;327:737–747. PubMed PMC

Suverein MM, Delnoij TSR, Lorusso R, Brandon Bravo Bruinsma GJ, Otterspoor L, Elzo Kraemer CV, et al. . Early extracorporeal CPR for refractory out-of-hospital cardiac arrest. N Engl J Med 2023;388:299–309. PubMed

Yannopoulos D, Kalra R, Kosmopoulos M, Walser E, Bartos JA, Murray TA, et al. . Rationale and methods of the Advanced R(2)Eperfusion STrategies for Refractory Cardiac Arrest (ARREST) trial. Am Heart J 2020;229:29–39. PubMed

Bol ME, Suverein MM, Lorusso R, Delnoij TSR, Brandon Bravo Bruinsma GJ, Otterspoor L, et al. . Early initiation of extracorporeal life support in refractory out-of-hospital cardiac arrest: design and rationale of the INCEPTION trial. Am Heart J 2019;210:58–68. PubMed

Suverein MM, Shaw D, Lorusso R, Delnoij TSR, Essers Be, Weerwind PW, et al. . Ethics of ECPR research. Resuscitation 2021;169:136–142. PubMed

Miyamoto Y, Matsuyama T, Goto T, Ohbe H, Kitamura T, Yasunaga H, et al. . Association between age and neurological outcomes in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation: a nationwide multicentre observational study. Eur Heart J Acute Cardiovasc Care 2022;11:35–42. PubMed

Tanguay-Rioux X, Grunau B, Neumar R, Tallon J, Boone R, Christenson J. Is initial rhythm in OHCA a predictor of preceding no flow time? Implications for bystander response and ECPR candidacy evaluation. Resuscitation 2018;128:88–92. PubMed

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

Tonna JE, Selzman CH, Girotra S, Presson AP, Thiagarajan RR, Becker LB, et al. . Resuscitation using ECPR during in-hospital cardiac arrest (RESCUE-IHCA) mortality prediction score and external validation. JACC Cardiovasc Interv 2022;15:237–247. PubMed PMC

Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 2014;14:135. PubMed PMC

Fukushima K, Aoki M, Nakajima J, Aramaki Y, Ichikawa Y, Isshiki Y, et al. . Favorable prognosis by extracorporeal cardiopulmonary resuscitation for subsequent shockable rhythm patients. Am J Emerg Med 2022;53:144–149. PubMed

Havranek S, Fingrova Z, Rob D, Smalcova J, Kavalkova P, Franek O, et al. . Initial rhythm and survival in refractory out-of-hospital cardiac arrest. Post-hoc analysis of the Prague OHCA randomized trial. Resuscitation 2022;181:289–296. PubMed

Belohlavek J, Yannopoulos D, Smalcova J, Rob D, Bartos J, Huptych M, et al. . Intraarrest transport, extracorporeal cardiopulmonary resuscitation, and early invasive management in refractory out-of-hospital cardiac arrest: an individual patient data pooled analysis of two randomised trials. EClinicalMedicine 2023;59:101988. PubMed PMC

Higashi A, Nakada TA, Imaeda T, Abe R, Shinozaki K, Oda S. Shortening of low-flow duration over time was associated with improved outcomes of extracorporeal cardiopulmonary resuscitation in in-hospital cardiac arrest. J Intensive Care 2020;8:39. PubMed PMC

Bharmal MI, Venturini JM, Chua RFM, Sharp WW, Beiser DG, Tabit CE, et al. . Cost-utility of extracorporeal cardiopulmonary resuscitation in patients with cardiac arrest. Resuscitation 2019;136:126–130. 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;134:2084–2094. PubMed PMC

Yannopoulos D, Bartos JA, Raveendran G, Conterato M, Frascone RJ, Trembley A, et al. . Coronary artery disease in patients with out-of-hospital refractory ventricular fibrillation cardiac arrest. J Am Coll Cardiol 2017;70:1109–1117. PubMed

Yannopoulos D, Bartos JA, Martin C, Raveendran G, Missov E, Conterato M, et al. . Minnesota Resuscitation consortium's advanced perfusion and reperfusion cardiac life support strategy for out-of-hospital refractory ventricular fibrillation. J Am Heart Assoc 2016;5:e003732. PubMed PMC

Koen J, Nathanael T, Philippe D. A systematic review of current ECPR protocols. A step towards standardisation. Resusc Plus 2020;3:100018. PubMed PMC

Matsuyama T, Irisawa T, Yamada T, Hayakawa K, Yoshiya K, Noguchi K, et al. . Impact of low-flow duration on favorable neurological outcomes of extracorporeal cardiopulmonary resuscitation after out-of-hospital cardiac arrest: a multicenter prospective study. Circulation 2020;141:1031–1033. PubMed

Mandigers L, Boersma E, den Uil CA, Gommers D, Bělohlávek J, Belliato M, et al. . Systematic review and meta-analysis comparing low-flow duration of extracorporeal and conventional cardiopulmonary resuscitation. Interact Cardiovasc Thorac Surg 2022;35:ivac219. PubMed PMC

United States Census Reporter . https://censusreporter.org/profiles/31000US33460-minneapolis-st-paul-bloomington-mn-wi-metro-area/(17th Januari 2023).

European Metropolitean Transport Authorities . https://www.emta.com/spip.php?article23&lang=en(17th January 2023).

Tonna JE, Selzman CH, Bartos JA, Presson AP, Ou Z, Jo Y, et al. . The association of modifiable postresuscitation management and annual case volume with survival after extracorporeal cardiopulmonary resuscitation. Crit Care Explor 2022;4:e0733. PubMed PMC

Matsuoka Y, Goto R, Atsumi T, Morimura N, Nagao K, Tahara Y, et al. . Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a multi-centre prospective cohort study. Resuscitation 2020;157:32–38. PubMed

Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, et al. . 2021 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the basic life support; advanced life support; neonatal life support; education, implementation, and teams; first aid task forces; and the COVID-19 working group. Circulation 2022;145:e645–e721. PubMed

Ryan EG, Lamb SE, Williamson E, Gates S. Bayesian adaptive designs for multi-arm trials: an orthopaedic case study. Trials 2020;21:83. PubMed PMC

Yarnell CJ, Abrams D, Baldwin MR, Brodie D, Fan E, Ferguson ND, et al. . Clinical trials in critical care: can a Bayesian approach enhance clinical and scientific decision making? Lancet Respir Med 2021;9:207–216. PubMed PMC

Keaney JF Jr, Münzel T. Extracorporeal CPR in out-of-hospital cardiac arrest—still on life support? N Engl J Med 2023;388:370–371. PubMed

Sedgwick P. Explanatory trials versus pragmatic trials. BMJ 2014;349:g6694. PubMed

Dal-Re R, Janiaud P, Ioannidis JPA. Real-world evidence: how pragmatic are randomized controlled trials labeled as pragmatic? BMC Med 2018;16:49. PubMed PMC

Thorpe KE, Zwarenstein M, Oxman AD, Treweek S, Furberg CD, Altman DG, et al. . A Pragmatic-Explanatory Continuum Indicator Summary (PRECIS): a tool to help trial designers. CMAJ 2009;180:E47–E57. PubMed PMC

Treweek S, Zwarenstein M. Making trials matter: pragmatic and explanatory trials and the problem of applicability. Trials 2009;10:37. PubMed PMC

Loudon K, Treweek S, Sullivan F, Donnan P, Thorpe KE, Zwarenstein M. The PRECIS-2 tool: designing trials that are fit for purpose. BMJ 2015;350:h2147. PubMed

Rob D, Smalcova J, Smid O, Kral A, Kovarnik T, Zemanek D, et al. . Extracorporeal versus conventional cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: a secondary analysis of the Prague OHCA trial. Crit Care 2022;26:330. PubMed PMC

Addison D, Cheng E, Forrest P, Livingstone A, Morton RL, Dennis M. Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for adult out-of-hospital cardiac arrest: a systematic review. Resuscitation 2022;178:19–25. PubMed

Neurological Monitoring and Management for Adult Extracorporeal Membrane Oxygenation Patients: Extracorporeal Life Support Organization Consensus Guidelines

Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines

Extracorporeal cardiopulmonary resuscitation versus standard treatment for refractory out-of-hospital cardiac arrest: a Bayesian meta-analysis