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Observational Study
. 2021 May 22;25(1):174.
doi: 10.1186/s13054-021-03606-5.

Mechanical circulatory support for refractory out-of-hospital cardiac arrest: a Danish nationwide multicenter study

Sivagowry Rasalingam Mørk  1 , Carsten Stengaard  2 , Louise Linde  3 , Jacob Eifer Møller  3 , Lisette Okkels Jensen  3 , Henrik Schmidt  4 , Lars Peter Riber  5 , Jo Bønding Andreasen  6 , Sisse Anette Thomassen  6 , Helle Laugesen  6 , Phillip Michael Freeman  7 , Steffen Christensen  8 , Jacob Raben Greisen  8 , Mariann Tang  9 , Peter Hasse Møller-Sørensen  10 , Lene Holmvang  11 , Emilie Gregers  11 , Jesper Kjaergaard  11 , Christian Hassager  11 , Hans Eiskjær  2 , Christian Juhl Terkelsen  2   12
Affiliations
Observational Study

Mechanical circulatory support for refractory out-of-hospital cardiac arrest: a Danish nationwide multicenter study

Sivagowry Rasalingam Mørk et al. Crit Care. .

Abstract

Background: Mechanical circulatory support (MCS) with either extracorporeal membrane oxygenation or Impella has shown potential as a salvage therapy for patients with refractory out-of-hospital cardiac arrest (OHCA). The objective of this study was to describe the gradual implementation, survival and adherence to the national consensus with respect to use of MCS for OHCA in Denmark, and to identify factors associated with outcome.

Methods: This retrospective, observational cohort study included patients receiving MCS for OHCA at all tertiary cardiac arrest centers (n = 4) in Denmark between July 2011 and December 2020. Logistic regression and Kaplan-Meier survival analysis were used to determine association with outcome. Outcome was presented as survival to hospital discharge with good neurological outcome, 30-day survival and predictors of 30-day mortality.

Results: A total of 259 patients were included in the study. Thirty-day survival was 26%. Sixty-five (25%) survived to hospital discharge and a good neurological outcome (Glasgow-Pittsburgh Cerebral Performance Categories 1-2) was observed in 94% of these patients. Strict adherence to the national consensus showed a 30-day survival rate of 30% compared with 22% in patients violating one or more criteria. Adding criteria to the national consensus such as signs of life during cardiopulmonary resuscitation (CPR), pre-hospital low-flow < 100 min, pH > 6.8 and lactate < 15 mmol/L increased the survival rate to 48%, but would exclude 58% of the survivors from the current cohort. Logistic regression identified asystole (RR 1.36, 95% CI 1.18-1.57), pulseless electrical activity (RR 1.20, 95% CI 1.03-1.41), initial pH < 6.8 (RR 1.28, 95% CI 1.12-1.46) and lactate levels > 15 mmol/L (RR 1.16, 95% CI 1.16-1.53) as factors associated with increased risk of 30-day mortality. Patients presenting signs of life during CPR had reduced risk of 30-day mortality (RR 0.63, 95% CI 0.52-0.76).

Conclusions: A high survival rate with a good neurological outcome was observed in this Danish population of patients treated with MCS for OHCA. Stringent patient selection for MCS may produce higher survival rates but potentially withholds life-saving treatment in a significant proportion of survivors.

Keywords: Cardiopulmonary resuscitation; Extracorporeal membrane oxygenation; Impella; Mechanical circulatory support; Out-of-hospital cardiac arrest.

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Conflict of interest statement

Dr. Stengaard reports speaker’s fees from Rosche Diagnostics, outside the submitted work. Dr. Møller reports personal fees and grants from Orion Pharma, Novartis, Astra Zeneca, Abbott and Abiomed and served at scientific advisory board for Boehringer Ingelheim, outside the submitted work. Dr. Freeman reports grants from St. Jude and Astra Zeneca and personal fees from Meril Lifesciences and Edwards Lifesciences, outside the submitted work. Dr. Hassager reports grants from the Lundbeck Foundation and speaker’s honoraria from Abiomed, outside the submitted work. Dr. Kjaergaard reports non-financial participation in the advisory board for the CoCa Trial. Dr. Terkelsen is supported by an unrestricted research grant from the Danish Heart Foundation. The remaining authors have no conflicts of interest to declare.

Figures

Fig. 1
Fig. 1
National consensus and extended consensus with regional variances for selection of patients with refractory OHCA and possible candidates for mechanical circulatory support
Fig. 2
Fig. 2
Kaplan–Meier survival curves for patients with and without signs of life during cardiopulmonary resuscitation with respect to initial presenting rhythm and pre-hospital low-flow times. a Patients with initial shockable rhythm with signs of life and no signs of life. b Patients with non-shockable rhythm with signs of life and no signs of life. c Patients with pre-hospital low flow (PLF) 60–80 min with signs of life and no signs of life. d Patients with PLF > 80 min with signs of life and no signs of life
Fig. 3
Fig. 3
The impact of each selection criteria of the Danish national ECPR consensus in relation to survival to discharge with favorable neurological outcome (CPC 1–2). Survivors to discharge with CPC 1–2 in percentage when meeting selection criteria and failing to meet criteria of the national consensus
Fig. 4
Fig. 4
Kaplan–Meier survival curve for patients meeting the selection criteria and patients failing to meet the criteria. a Consensus A (National consensus): Survival analysis between patients meeting the Danish national consensus selection criteria in regards to younger age < 65 years, witnessed arrest, bystander CPR, initial shockable rhythm, no-flow < 10 min and end-tidal CO2 < 1.3 kPa, and patients failing to meet one or more criteria. b Consensus B (Extended version): Survival analysis based on a more refined assessment of selection criteria. Patients meeting all the selection criteria in the Danish national consensus and additionally one or more of following parameters: signs of life during CPR, pH > 6.8, lactate < 15 mmol/L and a pre-hospital low-flow < 100 min
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