Impact of Low-Flow Duration on Favorable Neurological Outcomes of Extracorporeal Cardiopulmonary Resuscitation After Out-of-Hospital Cardiac Arrest

Matsuyama, Tasuku; Irisawa, Taro; Yamada, Tomoki; Hayakawa, Koichi; Yoshiya, Kazuhisa; Noguchi, Kazuo; Nishimura, Tetsuro; Ishibe, Takuya; Yagi, Yoshiki; Kishimoto, Masafumi; Shintani, Hiroshi; Hayashi, Yasuyuki; Sogabe, Taku; Morooka, Takaya; Sakamoto, Haruko; Suzuki, Keitaro; Nakamura, Fumiko; Nishioka, Norihiro; Okada, Yohei; Matsui, Satoshi; Sado, Junya; Shimazu, Takeshi; Ohta, Bon; Iwami, Taku; Kitamura, Tetsuhisa

doi:10.1161/circulationaha.119.044285

Cited by 38 publications

(21 citation statements)

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“…Patients with shockable rhythm have also been associated with OHCA of cardiac causes and may benefit the most from early access to PCI 71 , 72 and intensive cardiac care. 65 Increased benefit in patients without ROSC also partially supports the view favoring quicker transport of patients with refractory OHCA to a hospital 73 , 74 , 75 , 76 instead of prolonging on‐scene resuscitation, 77 allowing patients to access advanced critical care and extracorporeal membrane oxygenation. These findings should be interpreted with caution, because the studies included for subgroup analysis were vulnerable to bias but offer preliminary evidence that EMS may consider prioritizing patients with shockable rhythm or without prehospital ROSC for transport to CACs.…”

Section: Discussionmentioning

confidence: 88%

Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out‐of‐Hospital Cardiac Arrest: A Systematic Review and Meta‐Analysis

Yeo

Goh

et al. 2022

JAHA

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Background The role of cardiac arrest centers (CACs) in out‐of‐hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out‐of‐hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self‐declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta‐analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty‐six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]), even when including high‐volume centers (aOR, 1.50 [95% CI, 1.18–1.91]) or including improved‐care centers (aOR, 2.13 [95% CI, 1.75–2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]), even when including high‐volume centers (aOR, 1.74 [95% CI, 1.38–2.18]) or when including improved‐care centers (aOR, 1.97 [95% CI, 1.71–2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm ( P =0.006) and without prehospital return of spontaneous circulation ( P =0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out‐of‐hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.

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Section: Discussionmentioning

confidence: 88%

Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out‐of‐Hospital Cardiac Arrest: A Systematic Review and Meta‐Analysis

Yeo

Goh

et al. 2022

JAHA

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“…8,[19][20][21][22][23] Prehospital time is also expected to be associated with the length of low-flow time. 18,25 Therefore, the scoring system proposed in this study can be explained by these factors.…”

Section: Discussionmentioning

confidence: 99%

Development and Validation of a Clinical Score to Predict Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation

et al. 2020

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IMPORTANCE Extracorporeal cardiopulmonary resuscitation (ECPR) is expected to improve the neurological outcomes of patients with refractory cardiac arrest; however, it is invasive, expensive, and requires substantial human resources. The ability to predict neurological outcomes would assist in patient selection for ECPR. OBJECTIVE To develop and validate a prediction model for neurological outcomes of patients with out-of-hospital cardiac arrest with shockable rhythm treated with ECPR. DESIGN, SETTING, AND PARTICIPANTS This prognostic study analyzed data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a multi-institutional nationwide cohort study that included 87 emergency departments in Japan. All adult patients with out-of-hospital cardiac arrest and shockable rhythm who were treated with ECPR between June 2014 and December 2017 were included. Patients were randomly assigned to the development and validation cohorts based on the institutions. The analysis was conducted between November 2019 and August 2020. EXPOSURES Age (<65 years), time from call to hospital arrival (Յ25 minutes), initial cardiac rhythm on hospital arrival (shockable), and initial pH value (Ն7.0). MAIN OUTCOMES AND MEASURES The primary outcome was 1-month survival with favorable neurological outcome, defined by Cerebral Performance Category 1 or 2. In the development cohort, a simple scoring system was developed to predict this outcome using a logistic regression model. The diagnostic ability and calibration of the scoring system were assessed in the validation cohort. RESULTS A total of 916 patients were included, 458 in the development cohort (median [interquartile range {IQR}] age, 61 [47-69] years, 377 [82.3%] men) and 458 in the validation cohort (median [IQR] age, 60 [49-68] years; 393 [85.8%] men). The cohorts had the same proportion of favorable neurological outcome (57 patients [12.4%]). The prediction scoring system was developed, attributing a score of 1 for each clinical predictor. Patients were divided into 4 groups, corresponding to their scores on the prediction model, as follows: very low probability (score 0), low probability (score 1), middle probability (score 2), and high probability (score 3-4) of good neurological outcome. The mean predicted probabilities in the groups stratified by score were as follows: very low, 1.6% (95% CI, 1.6%-1.6%); low, 4.4% (95% CI, 4.2%-4.6%); middle, 12.5% (95% CI, 12.1%-12.8%); and high, 30.8% (95% CI, 29.1%-32.5%). In the validation cohort, the C statistic of the scoring system was (continued) Key Points Question Can the neurological outcome of patients with out-ofhospital cardiac arrest and shockable rhythm who are treated with extracorporeal cardiopulmonary resuscitation (ECPR) be predicted using accessible information? Findings In this prognostic study of 916 patients, a model using time to hospital arrival, pH in initial blood gas assessment, shockable rhythm on hospital arrival, and being younger than 65 years was developed to predict survival ...

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“…Across studies, several factors have consistently been identified as portending worse prognosis for ECPR over conventional CPR, including older age, longer duration of low-flow time, and an initial non-shockable rhythm (Table 2) [13,15,23,40,41,[49][50][51][52][53][54][55]. One high-volume center in Taiwan demonstrated that the combination of age > 75 and low-flow time > 60 min resulted in 0% neurological or functional recovery [20].…”

Section: Patient-specific Factors Associated With Ecpr Outcomesmentioning

confidence: 99%

“…One high-volume center in Taiwan demonstrated that the combination of age > 75 and low-flow time > 60 min resulted in 0% neurological or functional recovery [20]. In a prospective study from Japan, one-month survival with CPC 1 or 2 was > 30% with low-flow time of 40 min in those with shockable rhythms compared to < 15% in nonshockable rhythms [51]. Other retrospective analyses have shown favorable outcomes despite prolonged lowflow time (> 45 min) when restricted to younger patients (≤ 43 years) [56], or when patients exhibit signs of life during CPR [55].…”

Section: Patient-specific Factors Associated With Ecpr Outcomesmentioning

confidence: 99%

Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications

et al. 2021

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Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.

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Impact of Low-Flow Duration on Favorable Neurological Outcomes of Extracorporeal Cardiopulmonary Resuscitation After Out-of-Hospital Cardiac Arrest

Cited by 38 publications

References 5 publications

Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out‐of‐Hospital Cardiac Arrest: A Systematic Review and Meta‐Analysis

Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out‐of‐Hospital Cardiac Arrest: A Systematic Review and Meta‐Analysis

Development and Validation of a Clinical Score to Predict Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation

Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications

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