Extracorporeal CPR
INCEPTION: Suverein MM, Delnoij TSR, Lorusso R, et al. Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. NEJM 2023 Jan 26;388(4):299-309.
- This was a multicenter, randomised controlled trial conducted in the Netherlands where 134 patients with an out-of-hospital cardiac arrest who had bystander CPR and an initial shockable rhythm were assigned to receive extracorporeal CPR or conventional CPR
- Results: No significant difference in survival at 30 days with favourable neurological outcome. E-CPR was associated with a higher proportion of patients who survived until admission to the ICU than conventional CPR. No E-CPR survivors had poor neurologic outcomes.
PRAGUE OHCA: Belohlavek J, Smalcova J, Rob D, et al. Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2022 Feb 22;327(8):737-747.
- This was a single centre RCT from Prague comparing ACLS with expedited transfer to the cath lab where ECMO was commenced followed by coronary angiography for patients with OOHCA and VTF/VT or PEA
- The study population was substantially larger in this trial compared to ARREST – there were 124 in the ECMO group vs 132 in the standard ACLS group
- Results: There was a trend of benefit but no statistical significance in increased survival with good neurological outcome at day 180 with ECMO (31.5% vs 22.0%, p=0.09)
- Note: there was a higher than expected survival rate with standard care (22%), where generally survival has been reported at ~10%
- The trial was stopped early due to futility criteria being met
ARREST: Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial Lancet. 2020;396(10265):1807-1816.
- This was a single centre RCT performed in Minnesota which compared standard ACLS with expedited transfer to the cath lab where ECMO was commenced followed by coronary angiography
- Results: ECMO significantly improved survival with 6/14 ECMO patients surviving (43%) vs 1/15 patients (6.7%) in the standard-care group. At 6 months, 3 patients in the ECMO group had a Modified Rankin Scale score ≤2, vs 0 patients in the standard-care group.
- This trial was stopped early due to benefit (the probability of ECMO superiority was estimated to be 98%)
Cardiogenic Shock
Thiele H, Zeymer U, Akin I, et al. Extracorporeal life support in infarct-related cardiogenic shock. NEJM. 2023;389(14):1286-1297.
- RCT from Germany and Slovenia of 417 patients in cardiogenic shock who were undergoing revascularization during acute MI
- If cardiac cath showed a reversible lesion, patients were randomised to receive ECLS or standard care
- Results: No difference in all-cause mortality at 30 days. ECMO resulted in longer ICU length of stay along with peripheral vascular complications and bleeding.
ECMO-CS: Ostadal P, Rokyta R, Karasek J, et al. Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial. Circulation. 2023 Feb 7;147(6):454-464
- Multicentre RCT from Czechia of 122 patients with severe cardiogenic shock who were randomised to immediate VA-ECMO or standard care
- There was a high rate of cross over between groups (patients randomised to standard care deterioriating and being placed on ECMO)
- Results: No significant difference in the composite primary outcome of death, resuscitated circulatory arrest, or the need for another mechanical circulatory support device within 30 days
- Be mindful that the crossover rate may have dampened any treatment effect from ECMO
Hypothermia
ICE-CRASH: Takauji S, Hayakawa M, Yamada D, et al. Outcome of extracorporeal membrane oxygenation use in severe accidental hypothermia with cardiac arrest and circulatory instability: A multicentre, prospective, observational study in Japan (ICE-CRASH study). Resuscitation. 2023 Jan;182:109663.
- Prospective multicenter study of 36 Japanese EDs of adult patients with a body temperature <32 °C from accidental hypothermia with either cardiac arrest or circulatory instability
- 242 patients met the inclusion criteria: 41 treated with ECMO and 201 treated with conventional therapy. The mean age was >80 years
- Rewarming occurred substantially faster in the ECMO group (5.6 °C/hour) than the non-ECMO group (1.3 °C/hour)
- Results: There was statistically significant improvement in survival in patients with cardiac arrest treated with ECMO (58% vs 21%). Secondary outcomes (including neurologically intact survival) also favoured ECMO. There was no difference in outcomes in the non-cardiac arrest group
Prekker ME, Rischall M, Carlson M, et al. Extracorporeal membrane oxygenation versus conventional rewarming for severe hypothermia in an urban emergency department. Acad Emerg Med. 2023 Jan;30(1):6-15.
- Retrospective chart review of ECMO vs conventional care for patients presenting to a single ED in Minnesota with severe hypothermia
- 44 patients over 14 years of age were identified, 25 who received ECMO and 19 who received conventional active rewarming. Patients treated with ECMO tended to be younger (44 vs 50 years), generally more ill, more likely to have cardiac arrest (84% vs 37%) and to be colder (24 vs 26 °C)
- Rewarming was much faster, with ECMO at 2.3 °C/hour over 4 hours (9.2 °C) vs 1.5 °C/hour over 4 hours (6 °C). Moreover, the rate of warming on average for the ECMO group was 7 °C/hour over the first hour postperfusion.
- Results: ECMO produced a statistically significant survival rate (71% vs 29%) for those in with severe hypothermia in cardiac arrest. There was no significant difference in rates of survival for all comers.
