Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications

Darryl Abrams^{1

2}, Graeme MacLaren³, Roberto Lorusso⁴, Susanna Price^{5

6}, Demetris Yannopoulos⁷, Leen Vercaemst⁸, Jan Bělohlávek⁹, Fabio S Taccone¹⁰, Nadia Aissaoui¹¹, Kiran Shekar^{12

13

14}, A Reshad Garan¹⁵, Nir Uriel¹⁶, Joseph E Tonna^{17

18}, Jae Seung Jung¹⁹, Koji Takeda²⁰, Yih-Sharng Chen²¹, Arthur S Slutsky^#^{22

23}, Alain Combes^#^{24

25}, Daniel Brodie^#^{26

27}

Affiliations

¹ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, 622 W168th St., PH 8E, Room 101, New York, NY, 10032, USA.
² Center for Acute Respiratory Failure, Columbia University Irving Medical Center, New York, NY, USA.
³ Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore.
⁴ Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
⁵ Adult Intensive Care Unit, Royal Brompton Hospital, London, UK.
⁶ National Heart and Lung Institute, Imperial College, London, UK.
⁷ Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.
⁸ Department of Perfusion, University Hospital Gasthuisberg, Leuven, Belgium.
⁹ Second Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.
¹⁰ Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
¹¹ Intensive Care Unit, APHP, Hopital Européen Georges Pompidou, Inserm U 970, Université de Paris, Paris, France.
¹² Adult Intensive Care Services, Prince Charles Hospital, Brisbane, Australia.
¹³ University of Queensland, Brisbane, Australia.
¹⁴ Bond University, Gold Coast, Australia.
¹⁵ Department of Medicine, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
¹⁶ Division of Cardiology, Department of Medicine, NewYork-Presbyterian, Columbia University Irving Medical Center, New York, NY, USA.
¹⁷ Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA.
¹⁸ Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA.
¹⁹ Department of Thoracic and Cardiovascular Surgery, Korea University Medicine, Seoul, Republic of Korea.
²⁰ Division of Cardiac, Vascular and Thoracic Surgery, Columbia University Medical Center, New York, USA.
²¹ Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
²² Keenan Research Center, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Canada.
²³ Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Canada.
²⁴ Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France.
²⁵ Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Institut de Cardiologie, Paris, France.
²⁶ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, 622 W168th St., PH 8E, Room 101, New York, NY, 10032, USA. hdb5@cumc.columbia.edu.
²⁷ Center for Acute Respiratory Failure, Columbia University Irving Medical Center, New York, NY, USA. hdb5@cumc.columbia.edu.

^# Contributed equally.

PMID: 34505911
PMCID: PMC8429884
DOI: 10.1007/s00134-021-06514-y

Review

Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications

Darryl Abrams et al. Intensive Care Med. 2022 Jan.

. 2022 Jan;48(1):1-15.

doi: 10.1007/s00134-021-06514-y. Epub 2021 Sep 10.

Authors

Affiliations

¹ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, 622 W168th St., PH 8E, Room 101, New York, NY, 10032, USA.
² Center for Acute Respiratory Failure, Columbia University Irving Medical Center, New York, NY, USA.
³ Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore.
⁴ Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
⁵ Adult Intensive Care Unit, Royal Brompton Hospital, London, UK.
⁶ National Heart and Lung Institute, Imperial College, London, UK.
⁷ Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.
⁸ Department of Perfusion, University Hospital Gasthuisberg, Leuven, Belgium.
⁹ Second Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.
¹⁰ Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
¹¹ Intensive Care Unit, APHP, Hopital Européen Georges Pompidou, Inserm U 970, Université de Paris, Paris, France.
¹² Adult Intensive Care Services, Prince Charles Hospital, Brisbane, Australia.
¹³ University of Queensland, Brisbane, Australia.
¹⁴ Bond University, Gold Coast, Australia.
¹⁵ Department of Medicine, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
¹⁶ Division of Cardiology, Department of Medicine, NewYork-Presbyterian, Columbia University Irving Medical Center, New York, NY, USA.
¹⁷ Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA.
¹⁸ Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA.
¹⁹ Department of Thoracic and Cardiovascular Surgery, Korea University Medicine, Seoul, Republic of Korea.
²⁰ Division of Cardiac, Vascular and Thoracic Surgery, Columbia University Medical Center, New York, USA.
²¹ Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
²² Keenan Research Center, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Canada.
²³ Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Canada.
²⁴ Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France.
²⁵ Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Institut de Cardiologie, Paris, France.
²⁶ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, 622 W168th St., PH 8E, Room 101, New York, NY, 10032, USA. hdb5@cumc.columbia.edu.
²⁷ Center for Acute Respiratory Failure, Columbia University Irving Medical Center, New York, NY, USA. hdb5@cumc.columbia.edu.

^# Contributed equally.

PMID: 34505911
PMCID: PMC8429884
DOI: 10.1007/s00134-021-06514-y

Abstract

Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.

Keywords: Cardiac arrest; Extracorporeal cardiopulmonary resuscitation; Extracorporeal membrane oxygenation; IHCA; OHCA.

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Conflict of interest statement

DA reports serving as an at-large member of the Steering Committee for the Extracorporeal Life Support Organization (ELSO). GM reports serving as a member of the board of directors for ELSO. RL reports personal fees from Medtronic and LivaNova, outside the submitted work; member of advisory boards of Eurosets and PulseCath; advisor to the board of directors of ELSO and a past president of the European chapter of ELSO (EuroELSO). DY receives NIH grant support for resuscitation and ECPR and a Helmsley Philanthropic Trust grant for Mobile ECPR Implementation. LV receives consulting fees from Medtronic, outside the submitted work. JB is the current president of EuroELSO. FST reports personal fees from BARD, outside the submitted work. KS receives research support from Metro North Hospital and Health Service, outside the submitted work, and is the research lead of the ELSO Education Task Force (ECMOed) and member of the steering and educational committees for the Asia–Pacific chapter of ELSO (APELSO). ARG is a member of the advisory board for Abbott. JET was supported by a career development award (K23HL141596) from the National Heart, Lung, And Blood Institute (NHLBI) of the National Institutes of Health (NIH), received speakers fees and travel compensation from LivaNova relevant to cardiac arrest, outside the submitted work, speaker fees and travel compensation from Philips Healthcare, outside the submitted work, and is Chair of the Scientific Oversight Committee for ELSO. JSJ is an at-large member of the Steering Committee for the Asia–Pacific chapter of APELSO. YSC is the past chair and current conference committee chair of APELSO. ASS and AC report grants and personal fees from MAQUET, Xenios, and Baxter. AC was a past president of EuroELSO. DB receives research support from ALung Technologies, has been on the medical advisory boards for Baxter, Abiomed, Xenios, and Hemovent, and is the President-elect and member of the board of directors for ELSO. SP, NA, KT, and NU have no disclosures to report.

Figures

**Fig. 1**
Complications associated with conventional CPR and ECPR. *ACLS* advanced cardiac life support, CO₂ carbon dioxide, *CPR* cardiopulmonary resuscitation, *ECPR* extracorporeal cardiopulmonary resuscitation, LV left ventricle

**Fig. 2**
Schematic representation of CPR and ECPR by location. Much like conventional CPR (blue shaded area), locations where ECPR may be initiated (pink shaded area) include: prior to arrival to the hospital (pre-hospital ECPR), emergency department, catheterization laboratory, intensive care unit, or other locations within the hospital where cardiac arrest may occur (e.g., operating room, inpatient ward). *CPR* cardiopulmonary resuscitation, *ECPR* extracorporeal cardiopulmonary resuscitation, *ICU* intensive care unit, *IHCA* in-hospital cardiac arrest, *Low-flow* time from initiation of CPR to initiation of ECPR, *No-flow* time between cardiac arrest and initiation of CPR, *OHCA* out-of-hospital cardiac arrest, *VAD* ventricular assist device

See this image and copyright information in PMC

References

1. Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW, American Heart Association Council on E, Prevention Statistics C, Stroke Statistics S Heart disease and stroke statistics-2020 update: a report from the American heart association. Circulation. 2020;141:e139–e596. - PubMed
1. Schluep M, Gravesteijn BY, Stolker RJ, Endeman H, Hoeks SE. One-year survival after in-hospital cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2018;132:90–100. - PubMed
1. Thompson LE, Chan PS, Tang F, Nallamothu BK, Girotra S, Perman SM, Bose S, Daugherty SL, Bradley SM, American Heart Association's Get With the Guidelines-Resuscitation I Long-term survival trends of medicare patients after in-hospital cardiac arrest: insights from get with the guidelines-resuscitation((R)) Resuscitation. 2018;123:58–64. - PMC - PubMed
1. Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS, American Heart Association Get with the Guidelines-Resuscitation I Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367:1912–1920. - PMC - PubMed
1. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, de Ferranti S, Despres JP, Fullerton HJ, Howard VJ, Huffman MD, Judd SE, Kissela BM, Lackland DT, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Matchar DB, McGuire DK, Mohler ER, 3rd, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Willey JZ, Woo D, Yeh RW, Turner MB, American Heart Association Statistics C, Stroke Statistics S Heart disease and stroke statistics–2015 update: a report from the American Heart Association. Circulation. 2015;131:322. - PubMed

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Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications

Affiliations

Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications

Authors

Affiliations

Abstract

Conflict of interest statement

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