This recently published study showed a threefold increase in survival compared to historical
controls. (See Figure 2, p. 14.) The main effect of
ECPR was a 2.5-fold higher ICU admission rate
compared to historical controls. ECMO-based
resuscitation provided the hemodynamic and
respiratory support for 45% of those patients to
survive to hospital discharge. Cardiac function
recovered almost universally as it can be seen in
the figure below based on survivors and nonsurvivors. (See Figure 3, p. 14.) Over two years, the
University of Minnesota has treated with its CCL
based ECPR protocol 121 patients. Survival has
remained unchanged to 45%.
The University of Utah has developed a similar
program based on ED ECPR initiation in conjunction with an early transport systems-based protocol
and have reported very encouraging 35% survival
rates in the first 17 patients over the last two years. 33
Words of Caution
Although ECLS provides a very promising new
tool in the armamentarium to treat OHCA, full
patient recovery requires a supporting system of
care after the intervention that needs to be better
understood and essentially redefined.
Odds of survival after cardiac arrest increase in
hospitals with full cardiovascular interventional
capabilities, even when patients don’t have specific
interventions. 34, 35
This observation suggests the culture of care
is different between sites, and we speculate that
experience improves care for patients with acute
Post-cardiac arrest intensive care has multiple
organ facets. 36 The most common cause of death
after reversal of cardiac arrest remains withdrawal
of life support because of presumed neurological
Accurate neurological prognostication is still an
area of research, and neurocritical care expertise
can be essential to prevent premature withdrawal
for patients with potential for recovery. 37
Every other organ system is also affected by
ischemia-reperfusion. 38 Therefore, multidisciplinary critical care, including access to support
services for all organ failures, may be necessary for
any post-arrest patient.
The full post-intensive care management palette
of rehabilitation and secondary prevention are essen-
tial to sustain the survival gains that are achieved
early with aggressive ECPR-based programs.
Access to implantable defibrillators cognitive,
functional and physical impairment management
are all paramount in the system preparation for
advanced ECPR based protocol initiations.
Need for a Randomized Trial
According to the 2015 American Heart Association
guidelines, “there is insufficient evidence to recom-
mend the routine use of ECPR for patients with
cardiac arrest.” 39 In studies published since 2015, sur-
vival ranged from 8.8% to 43.5% for ECPR in patients
with OHCA, 21, 27, 29–32 and up to 55.6% in patients with
v fib/v tach OHCA. 29 (See Table 1, p. 15.)
Although these results are encouraging, most
reports were retrospective, and all studies were
observational, with inherent selection bias that no
statistical adjustment can eliminate completely.
No randomized clinical trials have been performed. Wide variation in results stems from heterogeneous study populations, varying bystander
intervention, differences in prehospital EMS organizations, the lack of a standardized protocol for
ECPR with ECMO in refractory cardiac arrest,
differences in in-hospital care, and differences in
outcome criteria have resulted in widely varying
findings in published study results.
ECPR and ECMO use in the post-resuscitation
management of patients of OHCA refractory cardiac arrest has yielded highly promising results
by providing a therapeutic platform that, when
applied early and within 60 minutes from the
9-1-1 call, can potentially double survival. Costs
and infrastructure are major challenges. The need
to assess the role of ECMO on survival with a randomized clinical trial has matured. ✚
Demetris Yannopoulos, MD, is professor of medicine
and emergency medicine; the Robert Eddy Endowed Chair
in Cardiovascular Resuscitation; the medical director for
the Minnesota Resuscitation Consortium and the director of research for the interventional cardiology section
at the University of Minnesota. In collaboration with
Minneapolis/St. Paul EMS directors, he established the
first ECMO-based resuscitation protocol in the U.S. for
refractory v fib out-of-hospital cardiac arrest patients.
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3. Debaty G, Labarere J, Frascone RJ, et al. Long-term prognostic value
of gasping during out-of-hospital cardiac arrest. JAm Coll Cardiol. 2017;70( 12):1467–1476.
4. Garcia S, Drexel T, Bekwelem W, et al. Early access to the cardiac
catheterization laboratory for patients resuscitated from cardiac arrest due to a shockable rhythm: The Minnesota Resuscitation Consortium Twin Cities unified protocol. JAm Heart Assoc.
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