The Association of Modifiable Postresuscitation Management and Annual Case Volume With Survival After Extracorporeal Cardiopulmonary Resuscitation

Abstract

IMPORTANCE:It is not know if hospital-level extracorporeal cardiopulmonary resuscitation (ECPR) case volume, or postcannulation clinical management associate with survival outcomes. OBJECTIVES:To describe variation in postresuscitation management practices, and annual hospital-level case volume, for patients who receive ECPR and to determine associations between these management practices and hospital survival.DESIGN: Observational cohort study using case-mix adjusted survival analysis. SETTING AND PARTICIPANTS:Adult patients greater than or equal to 18 years old who received ECPR from the Extracorporeal Life Support Organization Registry from 2008 to 2019. MAIN OUTCOMES AND MEASURES:Generalized estimating equation logistic regression was used to determine factors associated with hospital survival, accounting for clustering by center. Factors analyzed included specific clinical management interventions after starting extracorporeal membrane oxygenation (ECMO) including coronary angiography, mechanical unloading of the left ventricle on ECMO (with additional placement of a peripheral ventricular assist device, intra-aortic balloon pump, or surgical vent), placement of an arterial perfusion catheter distal to the arterial return cannula (to mitigate leg ischemia); potentially modifiable on-ECMO hemodynamics (arterial pulsatility, mean arterial pressure, ECMO flow); plus hospital-level annual case volume for adult ECPR. RESULTS:Case-mix adjusted patient-level management practices varied widely across individual hospitals. We analyzed 7,488 adults (29% survival); median age 55 (interquartile range, 44-64), 68% of whom were male. Adjusted hospital survival on ECMO was associated with mechanical unloading of the left ventricle (odds ratio [OR], 1.3; 95% CI, 1.08-1.55; p = 0.005), performance of coronary angiography (OR, 1.34; 95% CI, 1.11-1.61; p = 0.002), and placement of an arterial perfusion catheter distal to the return cannula (OR, 1.39; 95% CI, 1.05-1.84; p = 0.022). Survival varied by 44% across hospitals after case-mix adjustment and was higher at centers that perform more than 12 ECPR cases/yr (OR, 1.23; 95% CI, 1.04-1.45; p = 0.015) versus medium-and low-volume centers. CONCLUSIONS AND RELEVANCE:Modifiable ECMO management strategies and annual case volume vary across hospitals, appear to be associated with survival and should be the focus of future research to test if these hypothesisgenerating associations are causal in nature.

Refractory out‐of‐hospital cardiac arrest and extracorporeal cardiopulmonary resuscitation: A meta‐analysis of randomized trials

“…However, others revealed a minor or no effect on survival 17,25 . Such conflicting results probably arose from the heterogeneity in the strength of the chain of survival, patient selection criteria, adopted strategy, logistical organization, center experience, and post‐resuscitation care practice (e.g., advanced circulatory and ventilatory support, temperature management, and prognostication/withdrawal of life‐support therapy), leading to highly variable survival rates 26 …”

“…Implementing extracorporeal CPR in different settings and healthcare systems might fail to reproduce the beneficial effect observed in this meta‐analysis or single‐center RCTs. Moreover, a strong relationship exists between center experience with extracorporeal CPR, estimated by the annual case volume, and outcomes 26 . In the process of implementing extracorporeal CPR, centers should critically assess their logistics and monitor the program's performance.…”

“…17,25 Such conflicting results probably arose from the heterogeneity in the strength of the chain of survival, patient selection criteria, adopted strategy, logistical organization, center experience, and post-resuscitation care practice (e.g., advanced circulatory and ventilatory support, temperature management, and prognostication/ withdrawal of life-support therapy), leading to highly variable survival rates. 26 After decades of evidence in support for extracorporeal CPR limited to observational studies, three single-center RCTs, 8,9,18 of which one pilot trial, 18 and one multi-center, T A B L E 2 Summary of major findings on the effect of extracorporeal conventional cardiopulmonary versus conventional cardiopulmonary resuscitation.…”

“…Moreover, a strong relationship exists between center experience with extracorporeal CPR, estimated by the annual case volume, and outcomes. 26 In the process of implementing extracorporeal CPR, centers should critically assess their logistics and monitor the program's performance.…”

Extracorporeal CPR after the INCEPTION trial: No one steps twice into the same river

“…An analysis of the Extracorporeal Life Support Organization (ELSO) registry suggested that survival after ECPR was associated with modifiable post‐resuscitation practices and center volume 13 . Likewise, low volume per center, absence of standardization, and delays in how ECPR was provided in the INCEPTION trial may have contributed to its reduced effect, being, per definition, a time‐dependent intervention.…”