Multi-dimensional outcomes following extracorporeal cardiopulmonary resuscitation

Abstract

Background: Recent trials suggested that extracorporeal cardio-pulmonary resuscitation (ECPR) with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or "ECMELLA" (VA-ECMO plus Impella®) may improve short-term survival and neurological outcomes in selected patients with refractory cardiac arrest. However, long-term effects on cardiac, cognitive, physical and psychological health need further study. A multidisciplinary post-ECPR outpatient care program was developed at two centers, involving cardiologists, neurologists, psychologists and medical sociologists to assess seven key health dimensions.

Methods: This bicentric, multidisciplinary study, conducted from May 2021 to April 2023, included adult ECPR survivors. Outcomes were assessed approximately 22 months post-cardiac arrest, focusing on cardiac, neurological, psychological and multi-organ functions, as well as social, professional and physical performance.

Results: This study included 33 ECPR survivors, who were predominantly male (70%) with a mean age of 55 years. Left-ventricular ejection fraction improved significantly, from 22% during ICU stay to 51% at follow-up in the ECMELLA group and from 31% to 51% in the VA-ECMO group (p = 0.006). Many patients reported dizziness or dyspnea (>52%) during daily activities, with a median New York Heart Association class of 2, EQ-5D-5L score of 53 and elevated NT-proBNP levels. Despite normal neurological scores, 46% had memory issues, 39% struggled with daily organization, 52% had depression and 12% had suicidal thoughts. Physical performance was reduced, with a mean distance of 394 meters in the 6-minute walk test and a 6-minute bicycle ergometry time.

Conclusion: ECPR patients showed significant improvement in left ventricular function over time but their neuropsychological and physical abilities remained compromised. Timely, multidisciplinary rehabilitation is required, starting in the intensive care unit and extending to include psychological support and community reintegration strategies after discharge.

Keywords: Cardiac arrest; Extracorporeal cardio-pulmonary resuscitation; Myocardial recovery; Post-resuscitation program; Psychological effect.

Fig. 1

Concept of post-ECPR outpatient care program. The post-ECPR outpatient care program was meticulously developed through a multidisciplinary collaboration with cardiologists, neurologists, psychologists and medical sociologists. The program encompasses seven dimensions of comprehensive, long-term patient assessment, which are derived from the COSCA endorsed by the ILCOR. COSCA, “Core Outcome Set for Cardiac Arrest”; CPC, Cerebral Performance Category; ECPR, extracorporeal cardio-pulmonary resuscitation; ILCOR, International Liaison Committee on Resuscitation. Created in BioRender. https://biorender.com/q80m167

Fig. 2

Study subject flow diagram. In total, 39 ECPR survivors were invited to attend the post-ECPR outpatient care center. Six patients were excluded due to death or refusal to participate. Among the 33 participants, 18 had received an ECMELLA device, while 15 had undergone therapy with VA-ECMO only during the initial cardiac arrest event. ECMELLA, combined therapy with VA-ECMO and Impella®; ECPR, extracorporeal cardio-pulmonary resuscitation; VA-ECMO, veno-arterial extracorporeal membrane oxygenation.

Fig. 3

Left-ventricular function after ECPR. Transthoracic echocardiography was conducted by experienced cardiologists to quantify the LVEF both during the initial hospitalization following the cardiac arrest event and at the follow-up examination at the post-ECPR outpatient care center. Patients who received left-ventricular unloading (ECMELLA) exhibited a significantly greater improvement in LVEF compared to those treated with VA-ECMO alone (p = 0.006). Specifically, the LVEF in the ECMELLA group improved from 22% (±12) during the initial ICU stay to 51% (±9) at follow-up, while the LVEF in the VA-ECMO group improved from 31% (±15) to 51% (±9). ECMELLA, combined therapy with VA-ECMO and Impella®; ECPR, extracorporeal cardio-pulmonary resuscitation; ICU, intensive care unit; LVEF, left-ventricular ejection fraction; VA-ECMO, veno-arterial extracorporeal membrane oxygenation.