International Consensus on Evidence Gaps and Research Opportunities in Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest: A Report From the National Heart, Lung, and Blood Institute Workshop

Abstract

The increased accessibility of extracorporeal membrane oxygenation following the COVID-19 pandemic and the publication of the first randomized trial of extracorporeal cardiopulmonary resuscitation (ECPR) prompted the National Heart, Lung, and Blood Institute to sponsor a workshop on ECPR. Two more randomized trials have since been published in 2022 and 2023. Based on the combined findings and review of the evidence, an international panel of authors identified gaps in science, inequities in care and diversity in outcomes, and suggested research opportunities and next steps. The science pertaining to ECPR would benefit from the United States contributing uniform data to existing registries and sharing common data with the ELSO (Extracorporeal Life Support Organization) international registry to increase the sample size for observational research. In addition, well-designed efficacy trials, recruiting across different regions of care evaluating long-term follow-up, including patient reported outcomes, cost effectiveness, and equity measures, would contribute significantly to the body of science. Workshop participants defined the population of patients with out-of-hospital cardiac arrest most likely to benefit from ECPR. ECPR-eligible patients include those aged 18 to 75 years functioning independently without comorbidity; before suffering a witnessed out-of-hospital cardiac arrest and without any obvious cause of the cardiac arrest; presenting in a shockable rhythm and transported with mechanical cardiopulmonary resuscitation to an ECPR-capable institute within 30 minutes, which is recommended after 3 rounds of advanced life support treatment without return of spontaneous circulation. There are significant inequities in out-of-hospital cardiac arrest care that need to be addressed such that outcomes are optimized for each target region before implementing ECPR in a clinical or implementation trial.

Keywords: consensus; evidence gaps; extracorporeal membrane oxygenation; out‐of‐hospital cardiac arrest.

Figure 1. Out‐of‐hospital chain of survival modification to include ECPR.

CPR indicates cardiopulmonary resuscitation; ECPR, extracorporeal cardiopulmonary resuscitation; ED, emergency department; EMS, emergency medical services; ICU, intensive care unit. Adapted from Mission: Lifeline Program Copyright © 2016, American Heart Association, Inc. The Creative Commonslicense does not apply to this content. Use of the material in any format is prohibited without written permission from the American Heart Association, Inc.

Figure 2. ECPR continuum of care: Subject to Inequity.

Provided with permission from collaborator, Dr Sarah Perlman's presentation to the National Heart, Lung, and Blood Institute of the US National Institutes of Health convened a virtual workshop on August 23 and 24, 2021; URL:https://www.nhlbi.nih.gov/events/2021/extracorporeal‐cpr‐ecpr‐out‐hospital‐cardiac‐arrest. bCPR indicates; CABG, coronary artery bypass graft; ECMO, extracorporeal membrane oxygenation; ECPR, extracorporeal cardiopulmonary resuscitation; bCPR, bystander CPR, EMS, emergency medical services; ICD, implantable cardioverter‐defibrillator; SES, socioeconomic status; and WLST, withdrawal of life‐sustaining therapy.

Figure 3. Mission Lifeline Resuscitation program: STEMI and Cardiac Resuscitation Systems of Care.

All system data, including coverage area, are self‐reported data. Adapted from Mission: Lifeline Program, copyright © 2017, American Heart Association, Inc. The Creative Commons license does not apply to this content. Use of the material in any format is prohibited without written permission from the American Heart Association, Inc. STEMI indicates ST‐segment–elevation myocardial infarction.