Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications

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.

A phased intervention bundle to decrease the mortality of patients with extracorporeal membrane oxygenation in intensive care unit

“…The survival of ECPR increased gradually throughout the study, although without significant difference. During the 13-18 months after bundle implementation, the survival of ECPR has reached up to 70%, which was much higher than in previous studies (38). This may be largely due to the refined management of hemodynamic management and accurate bedside ultrasound evaluation.…”

“Impact of age on management and prognosis of resuscitated sudden cardiac death patients”

“…Despite the improvements in management and treatment of SCD patients, we found a high morbidity and mortality in these patients. Current therapies such as extracorporeal cardiopulmonary resuscitation (ECPR) represent a promising option to improve their prognosis in certain settings [39] . However, in our environment, ECPR is not yet fully implemented.…”

Mechanical circulatory support in the treatment of cardiogenic shock

“…Of note, VA-ECMO can also be initiated during cardiac arrest, and this is referred to as extracorporeal cardiopulmonary resuscitation (ECPR) [60]. Although a detailed discussion of ECPR is beyond the scope of this review, it remains an active area of study, with supportive evidence from prospective datasets [61], as well as a small randomized trial [62].…”