Extracorporeal cardiopulmonary resuscitation for cardiac arrest: A systematic review

Abstract

Aim: To assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual or mechanical cardiopulmonary resuscitation (CPR), for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) in adults and children.

Methods: The PRISMA guidelines were followed. We searched Medline, Embase, and Evidence-Based Medicine Reviews for randomized clinical trials and observational studies published before May 22, 2018. The population included adult and pediatric patients with OHCA and IHCA of any origin. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Outcomes included short-term and long-term survival and favorable neurological outcome.

Results: We included 25 observational studies, of which 15 studies were in adult OHCA, 7 studies were in adult IHCA, and 3 studies were in pediatric IHCA. There were no studies in pediatric OHCA. No randomized trials were included. Results from individual studies were largely inconsistent, although several studies in adult and pediatric IHCA were in favor of ECPR. The risk of bias for individual studies was overall assessed to be critical, with confounding being the primary source of bias. The overall quality of evidence was assessed to be very low. Heterogeneity across studies precluded any meaningful meta-analyses.

Conclusions: There is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA in adults and children. The quality of evidence across studies is very low.

Keywords: Cardiac arrest; ECPR; Extracorporeal cardiopulmonary resuscitation.

Fig. 1.

PRISMA diagram. Out of 7458 screened records, 74 articles were assessed for eligibility, and 25 studies were included.

Fig. 2.

Forest plots for adult out-of-hospital cardiac arrest. Forest plots for survival to hospital discharge/one month (A), long-term survival (B), favorable neurological outcome at hospital discharge/one month (C), and long-term favorable neurological outcome (D) in adult out-of-hospital cardiac arrest. The vertical red lines indicate odds ratios. Horizontal lines indicate 95% confidence intervals of the estimate. The studies are ordered by alphabetical order within each outcome. The forest plots for long-term outcomes are representative of all included patients, independent of survival to hospital discharge. The studies by Cesana et al. Lee et al. and Venturini et al. included both out-of-hospital cardiac arrest and in-hospital cardiac arrest patients. There was some overlap between the studies by Hase, Maekawa and Tanno, and between Yannopolous (2016 + 2017). OHCA refers to out-of-hospital cardiac arrest.

Fig. 3.

Forest plots for adult in-hospital cardiac arrest. Forest plots for survival to hospital discharge/ one month (A), long-term survival (B), favorable neurological outcome at hospital discharge/one month (C), long-term favorable neurological outcome (D), and survival analysis (E) in adult in-hospital cardiac arrest. The vertical red lines indicate odds ratios or hazard ratios. Horizontal lines indicate 95% confidence intervals of the estimate. For the survival analysis (hazard ratios from Cox proportional hazard models) with time-to-death as the outcome, estimates below 1 are in favor of ECPR. The studies are ordered by alphabetical order within each outcome. The forest plots for long-term outcomes are representative of all included patients, independent of survival to hospital discharge. There was some overlap between the studies by Chen and Lin, and between Cho and Shin (2011 + 2013). IHCA refers to in-hospital cardiac arrest.

Fig. 4.

Forest plots for pediatric in-hospital cardiac arrest. Forest plots for survival to hospital discharge (A) and favorable neurological outcome at hospital discharge (B) in pediatric in-hospital cardiac arrest. The vertical red lines indicate odds ratios. Horizontal lines indicate 95% confidence intervals of the estimate. The studies are ordered by alphabetical order within each outcome. The 95% confidence interval reported by Ortmann et al. (medical-group) was non-symmetric and therefore re-estimated. There was some overlap between the studies by Lasa et al. and Ortmann et al IHCA refers to in-hospital cardiac arrest.