Enhancing cardiac arrest survival with extracorporeal cardiopulmonary resuscitation: insights into the process of death

Abstract

Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging method of cardiopulmonary resuscitation to improve outcomes from cardiac arrest. This approach targets patients with out-of-hospital cardiac arrest previously unresponsive and refractory to standard treatment, combining approximately 1 h of standard CPR followed by venoarterial extracorporeal membrane oxygenation (VA-ECMO) and coronary artery revascularization. Despite its relatively new emergence for the treatment of cardiac arrest, the approach is grounded in a vast body of preclinical and clinical data that demonstrate significantly improved survival and neurological outcomes despite unprecedented, prolonged periods of CPR. In this review, we detail the principles behind VA-ECMO-facilitated resuscitation, contemporary clinical approaches with outcomes, and address the emerging new understanding of the process of death and capability for neurological recovery.

Impact of left ventricular unloading using a peripheral Impella®‐pump in eCPR patients

“…Other mechanical support devices might also improve mortality and outcome. An intra‐aortic balloon pump (IABP) might also be beneficial concomitant to V‐A ECMO therapy in eCPR patients due to its counter pulsatile fashion 22,23 . Recently, Aufderheide et al published an article concerning the general management of eCPR patients in the ICU.…”

“…Recently, Aufderheide et al published an article concerning the general management of eCPR patients in the ICU. Their manuscript describes additional support with IABP (intra‐aortic balloon pump) in eCPR patients without the need for additional implantation of an Impella® device or additional vent 23 . Concerning the impressive survival rates after eCPR in Minneapolis, this strategy is worthy of further investigation.…”

“…An intra-aortic balloon pump (IABP) might also be beneficial concomitant to V-A ECMO therapy in eCPR patients due to its counter pulsatile fashion. 22,23 Recently, Aufderheide et al published an article concerning the general management of eCPR patients in the ICU. Their manuscript describes additional support with IABP (intraaortic balloon pump) in eCPR patients without the need for additional implantation of an Impella® device or additional vent.…”

Pediatric Extracorporeal Cardiopulmonary Resuscitation: Development of a Porcine Model and the Influence of Cardiopulmonary Resuscitation Duration on Brain Injury

“…In this study, we successfully developed and piloted a porcine model of prolonged pediatric cardiac arrest of 30 and 60 minutes’ duration followed by 24 hours of extracorporeal life support (ECLS)‐facilitated postcardiac arrest care. To our knowledge, this is the first large‐animal model in decades to investigate CPR >45 minutes, 3 , 4 , 5 , 6 , 7 , 29 , 30 as well as to invasively measure postarrest cerebral hemodynamic, metabolic, and oxygenation parameters for 24 hours after arrest. In our proof‐of‐concept study investigating the impact of CPR duration on the severity of brain injury 24 hours after cardiac arrest, all animals suffered neurological injury ( Table ), but the severity of injury was not demonstrably different between groups nor entirely explained by CPR duration.…”

“…The earliest possible reestablishment of sustained blood flow is critical to survival and neurological outcome, and extracorporeal cardiopulmonary resuscitation (ECPR) techniques are now widely used for refractory cardiac arrests. In children with cardiac diagnoses in well‐equipped centers, ECPR is associated with improved survival and neurological recovery after prolonged in‐hospital cardiac arrest 3 , 4 , 5 , 6 , 7 and is now endorsed in resuscitation guidelines 8 for these patients. High‐quality research is necessary to extend ECPR to other populations and settings and to optimize its functionality and outcomes.…”