Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest - current status

Abstract

Purpose of review: Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging treatment for refractory cardiac arrest. In recent years, several randomized controlled trials have been published that aimed to address the efficacy and effectiveness of ECPR for out-of-hospital cardiac arrest (OHCA). Despite the lack of high-quality evidence concerning clinical effectiveness and cost-effectiveness, ECPR is increasingly implemented throughout the world. In this review, we aim to provide an overview of the current status of ECPR for OHCA.

Recent findings: Randomized controlled trials showed diverging results, largely due to differences in selection criteria and study design. Single-center studies, performed in centers with extraordinary expertise and dedication consistently achieve a low-flow time of around 60 min, but such achievements are rarely reproduced outside these centers. Strict patient selection can improve outcome but simultaneously limits the caseload. Preliminary data suggest that outcome may also be improved by avoiding hyperoxia postresuscitation.

Summary: The potential of ECPR to increase survival in selected patients in highly dedicated systems seems to be proven, the question remains whether ECPR for OHCA can be widely implemented successfully and can develop into a sustainable, commonplace resource-effective treatment.

Box 1

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FIGURE 1

Procedure of in-hospital extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). The entire procedure of ECPR for OHCA contains several consecutive steps between cardiac arrest and start of ECMO circulation. Each step of the procedure contains elements that can be optimized to create ideal conditions to perform ECPR and to limit low-flow times, ideally to less than 60 min. Transport times may be increased when a patient is transferred to an expert center, but timely announcement of an incoming ECPR candidate can facilitate the receiving center to perform logistic preparations during transport. Early activation of the process limits low-flow time but can lead to redundant ECPR system activation when patients regain ROSC during transport to the hospital. (a) Consecutive steps with points of improvement. (b) Optimal performing system.

FIGURE 2

Schematic representation of some factors of extracorporeal cardiopulmonary resuscitation (ECPR) that influence system performance. While stricter inclusion criteria for ECPR results in better outcome, it also suppresses the number of treated patients which lessens a center's experience and can decrease their system performance which can eventually diminish their outcome.