Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study.

A favorable neurological outcome is likely to be achieved in out-of-hospital cardiac arrest (OHCA) patients with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) on the initial electrocardiogram (ECG). However, in patients without pre-hospital restoration of spontaneous circulation despite the initial VF/VT, the outcome is extremely low by conventional cardiopulmonary resuscitation (CPR). Extracorporeal CPR (ECPR) may enhance cerebral blood flow and recovery of neurological function. We prospectively examined how ECPR for OHCA with VF/VT would affect neurological outcomes. The design of this trial was a prospective, observational study. We compared differences of outcome at 1 and 6 months after OHCA between ECPR group (26 hospitals) and non-ECPR group (20 hospitals). Primary endpoints were the rate of favorable outcomes defined by the Glasgow-Pittsburgh Cerebral Performance and Overall Performance Categories (CPC) 1 or 2 at 1 and 6 months after OHCA. Based on intention-to-treat analysis, CPC 1 or 2 were 12.3% (32/260) in the ECPR group and 1.5% (3/194) in the non-ECPR group at 1 month (P<0.0001), and 11.2% (29/260) and 2.6% (5/194) at 6 months (P=0.001), respectively. By per protocol analysis, CPC 1 or 2 were 13.7% (32/234) in the ECPR group and 1.9% (3/159) in the non-ECPR group at 1 month (P<0.0001), and 12.4% (29/234) and 3.1% (5/159) at 6 months (P=0.002), respectively. In OHCA patients with VF/VT on the initial ECG, a treatment bundle including ECPR, therapeutic hypothermia and IABP was associated with improved neurological outcome at 1 and 6 months after OHCA.

Sakamoto T ，Morimura N ，Nagao K ，Asai Y ，Yokota H ，Nara S ，Hase M ，Tahara Y ，Atsumi T ，SAVE-J Study Group ... -  《-》

Early initiation of extracorporeal life support in refractory out-of-hospital cardiac arrest: Design and rationale of the INCEPTION trial.

Return of spontaneous circulation occurs in less than 10% of patients with cardiac arrest undergoing cardiopulmonary resuscitation (CPR) for more than 15 minutes. Studies suggest that extracorporeal life support during cardiopulmonary resuscitation (ECPR) improves survival rate in these patients. These studies, however, are hampered by their non-randomized, observational design and are mostly single-center. A multicenter, randomized controlled trial is urgently warranted to evaluate the effectiveness of ECPR. We hypothesize that early initiation of ECPR in refractory out-of-hospital cardiac arrest (OHCA) improves the survival rate with favorable neurological status. The INCEPTION trial is an investigator-initiated, prospective, multicenter trial that will randomly allocate 110 patients to either continued CPR or ECPR in a 1:1 ratio. Patients eligible for inclusion are adults (≤ 70 years) with witnessed OHCA presenting with an initial rhythm of ventricular fibrillation (VF) or ventricular tachycardia (VT), who received bystander basic life support and who fail to achieve sustained return of spontaneous circulation within 15 minutes of cardiopulmonary resuscitation by emergency medical services. The primary endpoint of the study is 30-day survival rate with favorable neurological status, defined as 1 or 2 on the Cerebral Performance Category score. The secondary endpoints include 3, 6 and 12-month survival rate with favorable neurological status and the cost-effectiveness of ECPR compared to CCPR. The INCEPTION trial aims to determine the clinical benefit for the use of ECPR in patients with refractory OHCA presenting with VF/VT. Additionally, the feasibility and cost-effectiveness of ECPR will be evaluated.

Bol ME ，Suverein MM ，Lorusso R ，Delnoij TSR ，Brandon Bravo Bruinsma GJ ，Otterspoor L ，Kuijpers M ，Lam KY ，Vlaar APJ ，Elzo Kraemer CV ，van der Heijden JJ ，Scholten E ，Driessen AHG ，Montero Cabezas JM ，Rittersma SZH ，Heijnen BG ，Taccone FS ，Essers B ，Delhaas T ，Weerwind PW ，Roekaerts PMHJ ，Maessen JG ，van de Poll MCG ... -  《-》

Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest--a comparison with that for extracorporeal rescue for in-hospital cardiac arrest.

The aim was to investigate the effects of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) and compare the results with those of in-hospital cardiac arrest (IHCA). We analyzed our extracorporeal membrane oxygenation (ECMO) results for patients who received ECPR for OHCA or IHCA in the last 5 years. Pre-arrest, resuscitation, and post-resuscitative data were evaluated. In the last 5 years, ECPR was used 230 times for OHCA (n=31) and IHCA (n=199). The basic demographic data showed significant differences in age, cardiomyopathy, and location of the initial CPR. Duration of ischemia was shorter in the IHCA group (44.4±24.7 min vs. 67.5±30.6 min, p<0.05). About 50% of each group underwent a further intervention to treat the underlying etiology. ECMO was maintained for a shorter duration in the OHCA patients (61±48 h vs. 94±122 h, p<0.05). Survival to discharge was similar in the two groups (38.7% for OHCA vs. 31.2% for IHCA, p>0.05), as was the favorable outcome rate (25.5% for OHCA vs. 25.1% for IHCA, p>0.05). Survival was acceptable (about 33%) in both groups when the duration of ischemia was no longer than 75 min. In addition to having a beneficial effect in IHCA, ECPR can lead to survival and a positive neurological outcome in selected OHCA patients after prolonged resuscitation. Our results suggest that further investigation of the use of ECMO in OHCA is warranted.

Wang CH ，Chou NK ，Becker LB ，Lin JW ，Yu HY ，Chi NH ，Hunag SC ，Ko WJ ，Wang SS ，Tseng LJ ，Lin MH ，Wu IH ，Ma MH ，Chen YS ... -  《-》

Hospitals' extracorporeal cardiopulmonary resuscitation capabilities and outcomes in out-of-hospital cardiac arrest: A population-based study.

Extracorporeal cardiopulmonary resuscitation (ECPR) is the emerging resuscitative strategy to save refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) patients. We investigated whether the receiving hospitals' ECPR capabilities are associated with outcomes in out-of-hospital cardiac arrest (OHCA) patients who have refractory VF or pulseless VT. In a population-based cohort study performed in Kobe City, Japan, between 2010 and 2017, we identified all OHCA patients who had refractory VF or pulseless VT. Based on their ECPR capabilities, hospitals were categorised into ECPR facilities and conventional cardiopulmonary resuscitation (CCPR) facilities. We compared patient survivals between ECPR facilities and CCPR facilities by applying inverse probability weighting using a propensity score. Of all 10,971 OHCA patients, 518 had refractory VF or pulseless VT. The proportion of favourable neurologic outcomes was 43/188 (22.9%) in ECPR facilities and 28/330 (8.5%) in CCPR facilities. In the propensity analysis, hospitals' ECPR capabilities were associated with favourable neurologic outcomes (adjusted risk difference [ARD], 9.7% [95% confidence interval [CI], 3.7%-15.7%]; adjusted risk ratio [ARR], 2.01 [95% CI, 1.31-3.09]), and overall survival (87/188 [46.3%] vs. 67/330 [20.3%]; ARD, 19.0% [95% CI, 11.1%-26.9%]; ARR, 1.88 [95% CI, 1.45-2.44]). Hospitals' ECPR capabilities were associated with favourable neurologic outcomes in OHCA patients who had refractory VF or pulseless VT. We should take each hospital's ECPR capability into consideration when developing a regional system of care for OHCA.

Matsuoka Y ，Ikenoue T ，Hata N ，Taguri M ，Itaya T ，Ariyoshi K ，Fukuhara S ，Yamamoto Y ... -  《-》

Comparing extracorporeal cardiopulmonary resuscitation with conventional cardiopulmonary resuscitation: A meta-analysis.

The objective was to determine whether extracorporeal cardiopulmonary resuscitation (ECPR), when compared with conventional cardiopulmonary resuscitation (CCPR), improves outcomes in adult patients, and to determine appropriate conditions that can predict good survival outcome in ECPR patients through a meta-analysis. We searched the relevant literature of comparative studies between ECPR and CCPR in adults, from the MEDLINE, EMBASE, and Cochrane databases. The baseline information and outcome data (survival, good neurologic outcome at discharge, at 3-6 months, and at 1 year after arrest) were extracted. Beneficial effect of ECPR on outcome was analyzed according to time interval, location of arrest (out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA)), and pre-defined population inclusion criteria (witnessed arrest, initial shockable rhythm, cardiac etiology of arrest and CPR duration) by using Review Manager 5.3. Cochran's Q test and I(2) were calculated. 10 of 1583 publications were included. Although survival to discharge did not show clear superiority in OHCA, ECPR showed statistically improved survival and good neurologic outcome as compared to CCPR, especially at 3-6 months after arrest. In the subgroup of patients with pre-defined inclusion criteria, the pooled meta-analysis found similar results in studies with pre-defined criteria. Survival and good neurologic outcome tended to be superior in the ECPR group at 3-6 months after arrest. The effect of ECPR on survival to discharge in OHCA was not clearly shown. As ECPR showed better outcomes than CCPR in studies with pre-defined criteria, strict indications criteria should be considered when implementation of ECPR.

Kim SJ ，Kim HJ ，Lee HY ，Ahn HS ，Lee SW ... -  《-》