Extracorporeal cardiopulmonary resuscitation for in‐ and out‐of‐hospital cardiac arrest: systematic review and meta‐analysis of propensity score‐matched cohort studies

Abstract

Introduction In this systematic review and meta‐analysis of propensity score‐matched cohort studies, we quantitatively summarize whether venoarterial extracorporeal membrane oxygenation (VA‐ECMO) used as extracorporeal cardiopulmonary resuscitation (ECPR), compared with conventional cardiopulmonary resuscitation (CCPR), is associated with improved rates of 30‐day and long‐term favorable neurological outcomes and survival in patients resuscitated from in‐ and out‐of‐hospital cardiac arrest. Methods We searched MEDLINE via PubMed, Embase, Scopus, and Google Scholar for eligible studies on January 14, 2019. All searches were limited to studies published between January 2000 and January 2019. Two investigators independently evaluated the quality (or certainty) of evidence according to GRADE guidelines. Pooled results are presented as relative risks (RRs) with 95% confidence intervals (CIs). Results Six cohort studies using propensity score‐matched analysis were included, totaling 1108 matched patients. Pooled analyses showed that ECPR was likely associated with improved 30‐day and long‐term favorable neurological outcome in adults compared to CCPR for in‐ and out‐of‐hospital cardiac arrest (RR = 2.02, 95% CI = 1.29–3.16; I2 = 20%, P = 0.002; very low‐quality evidence) and (RR = 2.86, 95% CI = 1.64–5.01; I2 = 0%, P = 0.0002; moderate‐quality evidence), respectively. When we analyzed in‐ and out‐of‐hospital cardiac arrest separately, ECPR was likely associated with improved 30‐day favorable neurological outcome compared to CCPR for in‐hospital cardiac arrest (RR = 2.18, 95% CI = 1.24–3.81; I2 = 9%, P = 0.006; very low‐quality evidence), but not for out‐of‐hospital cardiac arrest (RR = 2.61, 95% CI = 0.56–12.20; I2 = 59%, P = 0.22; very low‐quality evidence). ECPR was also likely associated with improved long‐term favorable neurological outcome compared to CCPR for in‐hospital cardiac arrest (RR = 2.50, 95% CI = 1.33–4.71; I2 = 0%, P = 0.005; moderate‐quality evidence) and out‐of‐hospital cardiac arrest (RR = 4.64, 95% CI = 1.41–15.25; I2 = 0%, P = 0.01; moderate‐quality evidence). Conclusions Our analysis suggests that VA‐ECMO used as ECPR may improve long‐term favorable neurological outcomes and survival when compared to the best standard of care in a selected patient population. Therefore, it is imperative for well‐designed randomized clinical trials to obtain a higher level of scientific evidence to ensure optimal outcomes for cardiac arrest patients.

Extracorporeal cardiopulmonary resuscitation for adults with shock‐refractory cardiac arrest

“…Evidence from low-quality studies suggests that access to ECPR compared with no ECPR in patients resuscitated from refractory VF/pVT cardiac arrest is associated with a 2-to 4-fold increase in survival rates (10%-15% to 30%-45%). [78][79][80][81] As with many complex clinical interventions, the best results will be achieved by following a feasible and system-structural protocol with stringent patient selection.…”

Extracorporeal cardiopulmonary resuscitation in-hospital cardiac arrest due to acute coronary syndrome

“…A shockable rhythm during c-CPR is associated with better outcomes; however, if the chaotic heart rhythm does not return to its normal ejecting rhythm with at least three defibrillation attempts within 10 min, which is considered to be shock-refractory IHCA, persistent ventricular fibrillation would be associated with a fatal outcome due to permanent myocardial and/or neurological damage. [ 18 ] Essential properties of effective c-CPR with efficiency ability for more successful vital and neurological outcomes in IHCA patients have been published by several studies as follows: shockable initial rhythm (<3 times defibrillation within 10 min), shorter low-flow period (<10 min), lower total conversion-time form c-CPR to e-CPR (<30 to 40 min), non-increased blood lactate levels before e-CPR (<7 to 8 mmol/L), lower Sequential Organ Failure Assessment (SOFA) score and normal creatinine levels in the first 24 h after ICU admission (<1 mg/dL). [ 19 - 22 ] These factors could also benefit to identify which IHCA patients would benefit most from e-CPR.…”

“…Although the difference in other survival markers of the patients is striking, the restoration of the cardiac rhythm during e-CPR is also found to be one of the important factors for better survival in the literature. [ 18 , 23 - 26 ]…”

Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest: a scoping review

“…d Time from cardiac arrest to admission (min) in the ECPR group was 38 and 56 in the CCPR group. The time from admission to ECPR/ROSC (min) in the ECPR group was 55 (45-68) and 17 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27) in the CCPR group. e Time from 911 call to delivery to the CCL was 60.1 ± 11.…”

“…6 Multiple cohort studies have shown that such an approach has been associated with an increased rate of survival to discharge and neurologically intact survival compared with no ECPR or the standard of care, that is, conventional CPR. [6][7][8][9][10][11][12] However, only low quality evidence support the notion that this expensive and resource intensive strategy increases long-term neurologically intact survival after refractory cardiac arrest.…”