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. 2023 Jan 11;109(3):216-222.
doi: 10.1136/heartjnl-2022-321405.

Selection of patients for mechanical circulatory support for refractory out-of-hospital cardiac arrest

Louise Linde  1 , Sivagowry Rasalingam Mørk  2 , Emilie Gregers  3 , Jo Bønding Andreasen  4 , Jens Flensted Lassen  1 , Hanne Berg Ravn  5 , Henrik Schmidt  5 , Lars Peter Riber  6 , Sisse Anette Thomassen  4 , Helle Laugesen  4 , Hans Eiskjær  2 , Christian Juhl Terkelsen  7 , Steffen Christensen  8 , Mariann Tang  9 , Hasse Moeller-Soerensen  10 , Lene Holmvang  3 , Jesper Kjaergaard  3   10 , Christian Hassager  3   10 , Jacob Eifer Moller  11   3
Affiliations

Selection of patients for mechanical circulatory support for refractory out-of-hospital cardiac arrest

Louise Linde et al. Heart. .

Abstract

Objective: To describe characteristics of patients admitted with refractory cardiac arrest for possible extracorporeal cardiopulmonary resuscitation (ECPR) and gain insight into the reasons for refraining from treatment in some.

Methods: Nationwide retrospective cohort study involving all tertiary centres providing ECPR in Denmark. Consecutive patients admitted with ongoing chest compression for evaluation for ECPR treatment were enrolled. Presenting characteristics, duration of no-flow and low-flow time, end-tidal carbon dioxide (ETCO2), lactate and pH, and recording of reasons for refraining from ECPR documented by the treating team were recorded. Outcomes were survival to intensive care unit admission and survival to hospital discharge.

Results: Of 579 patients admitted with refractory cardiac arrest for possible ECPR, 221 patients (38%) proceeded to ECPR and 358 patients (62%) were not considered candidates. Median prehospital low-flow time was 70 min (IQR 56 to 85) in ECPR patients and 62 min (48 to 81) in no-ECPR patients, p<0.001. Intra-arrest transport was more than 50 km in 92 (42%) ECPR patients and 135 in no-ECPR patients (38%), p=0.25. The leading causes for not initiating ECPR stated by the treating team were duration of low-flow time in 39%, severe metabolic derangement in 35%, and in 31% low ETCO2. The prevailing combination of contributing factors were non-shockable rhythm, low ETCO2, and metabolic derangement or prehospital low-flow time combined with low ETCO2. Survival to discharge was only achieved in six patients (1.7%) in the no-ECPR group.

Conclusions: In this large nationwide study of patients admitted for possible ECPR, two-thirds of patients were not treated with ECPR. The most frequent reasons to abstain from ECPR were long duration of prehospital low-flow time, metabolic derangement and low ETCO2.

Keywords: EMERGENCY MEDICINE; Ethics, Medical; Heart-Assist Devices.

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Conflict of interest statement

Competing interests: JEM reports speaker fees and grants from Abiomed and served at the scientific advisory board for Boehringer Ingelheim, outside the submitted work. CH reports grants from the Lundbeck Foundation and speaker’s honoraria from Abiomed, outside the submitted work. JK reports non-financial participation in the advisory board for the CoCa Trial. CJT is supported by an unrestricted research grant from the Danish Heart Foundation. The remaining authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
(A) Distribution of contributing factors for not initiating ECPR in refractory OHCA. (B) Frequency of the number of recorded reasons. ECHO, echocardiography; ECPR, extracorporeal cardiopulmonary resuscitation; ETCO2, end-tidal carbon dioxide; OHCA, out-of-hospital cardiac arrest; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation.
Figure 2
Figure 2
Relationships maps of contributing factors for not initiating ECPR. Nodes represent cause for not initiating ECPR. Larger nodes and thicker lines represent stronger connections and associations whereas smaller nodes and thinner lines represent weaker connections and associations. (A) Patients with refractory OHCA less than 50 km from ECPR centre. (B) Patients with refractory OHCA more than 50 km from ECPR centre. ECPR, extracorporeal cardiopulmonary resuscitation; ETCO2, end-tidal carbon dioxide; OHCA, out-of-hospital cardiac arrest; PEA, pulseless electrical activity.
See this image and copyright information in PMC

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