OBJECTIVE: Compared to the conventional cardiopulmonary resuscitation (CCPR), potential benefits of extracorporeal cardiopulmonary resuscitation (ECPR) for patients with cardiac arrest (CA) are still controversial. We aimed to determine whether ECPR can improve the prognosis of CA patients compared with CCPR.
METHODS: We systematically searched PubMed, EMBASE, and Cochrane Library from database\'s inception to July 2023 to identify randomized controlled trials (RCTs) or cohort studies that compared ECPR with CCPR in adults (aged ≥ 16 years) with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). This meta-analysis was performed using a random-effects model. Two researchers independently reviewed the relevance of the study, extracted data, and evaluated the quality of the included literature. The primary outcome was short-term (from hospital discharge to one month after cardiac arrest) and long-term (≥ 90 days after cardiac arrest) survival with favorable neurological status (defined as cerebral performance category scores 1 or 2). Secondary outcomes included survival at 1 months, 3-6 months, and 1 year after cardiac arrest.
RESULTS: The meta-analysis included 3 RCTs and 14 cohort studies involving 167,728 patients. We found that ECPR can significantly improve good neurological prognosis (RR 1.82, 95%CI 1.42-2.34, I2 = 41%) and survival rate (RR 1.51, 95%CI 1.20-1.89, I2 = 62%). In addition, the results showed that ECPR had different effects on favorable neurological status in patients with OHCA (short-term: RR 1.50, 95%CI 0.98- 2.29, I2 = 55%; long-term: RR 1.95, 95% CI 1.06-3.59, I2 = 11%). However, ECPR had significantly better effects on neurological status than CCPR in patients with IHCA (short-term: RR 2.18, 95%CI 1.24- 3.81, I2 = 9%; long-term: RR 2.17, 95% CI 1.19-3.94, I2 = 0%).
CONCLUSIONS: This meta-analysis indicated that ECPR had significantly better effects on good neurological prognosis and survival rate than CCPR, especially in patients with IHCA. However, more high-quality studies are needed to explore the role of ECPR in patients with OHCA.

OBJECTIVE: Extracorporeal cardiopulmonary resuscitation (E-CPR) may improve survival with favorable neurological outcome in patients with refractory out-of-hospital cardiac arrest (OHCA). Unfortunately, recent results from randomized controlled trials were inconclusive. We performed a meta-analysis to investigate the impact of E-CPR on neurological outcome compared to conventional cardiopulmonary resuscitation (C-CPR).
METHODS: A systematic research for articles assessing outcomes of adult patients with OHCA either treated with E-CPR or C-CPR up to April 27, 2023 was performed. Primary outcome was survival with favorable neurological outcome at discharge or 30 days. Overall survival was also assessed.
RESULTS: Eighteen studies were included. E-CPR was associated with better survival with favorable neurological status at discharge or 30 days (14% vs 7%, OR 2.35, 95% CI 1.61-3.43, I2 = 80%, p < 0.001, NNT = 17) than C-CPR. Results were consistent if the analysis was restricted to RCTs. Overall survival to discharge or 30 days was also positively affected by treatment with E-CPR (OR = 1.71, 95% CI = 1.18-2.46, I2 = 81%, p = 0.004, NNT = 11).
CONCLUSIONS: In this meta-analysis, E-CPR had a positive effect on survival with favorable neurological outcome and, to a smaller extent, on overall mortality in patients with refractory OHCA.

BACKGROUND: The outcomes of several randomized trials on extracorporeal cardiopulmonary resuscitation (ECPR) in patients with refractory out-of-hospital cardiac arrest were examined using frequentist methods, resulting in a dichotomous interpretation of results based on p-values rather than in the probability of clinically relevant treatment effects. To determine such a probability of a clinically relevant ECPR-based treatment effect on neurological outcomes, the authors of these trials performed a Bayesian meta-analysis of the totality of randomized ECPR evidence.
METHODS: A systematic search was applied to three electronic databases. Randomized trials that compared ECPR-based treatment with conventional CPR for refractory out-of-hospital cardiac arrest were included. The study was preregistered in INPLASY (INPLASY2023120060). The primary Bayesian hierarchical meta-analysis estimated the difference in 6-month neurologically favorable survival in patients with all rhythms, and a secondary analysis assessed this difference in patients with shockable rhythms (Bayesian hierarchical random-effects model). Primary Bayesian analyses were performed under vague priors. Outcomes were formulated as estimated median relative risks, mean absolute risk differences, and numbers needed to treat with corresponding 95% credible intervals (CrIs). The posterior probabilities of various clinically relevant absolute risk difference thresholds were estimated.
RESULTS: Three randomized trials were included in the analysis (ECPR, n = 209 patients; conventional CPR, n = 211 patients). The estimated median relative risk of ECPR for 6-month neurologically favorable survival was 1.47 (95%CrI 0.73-3.32) with a mean absolute risk difference of 8.7% (- 5.0; 42.7%) in patients with all rhythms, and the median relative risk was 1.54 (95%CrI 0.79-3.71) with a mean absolute risk difference of 10.8% (95%CrI - 4.2; 73.9%) in patients with shockable rhythms. The posterior probabilities of an absolute risk difference > 0% and > 5% were 91.0% and 71.1% in patients with all rhythms and 92.4% and 75.8% in patients with shockable rhythms, respectively.
CONCLUSIONS: The current Bayesian meta-analysis found a 71.1% and 75.8% posterior probability of a clinically relevant ECPR-based treatment effect on 6-month neurologically favorable survival in patients with all rhythms and shockable rhythms. These results must be interpreted within the context of the reported credible intervals and varying designs of the randomized trials.
BACKGROUND: INPLASY (INPLASY2023120060, December 14th, 2023, https://doi.org/10.37766/inplasy2023.12.0060 ).

OBJECTIVE: The incidence of out-of-hospital cardiac arrest (OHCA) is high. Though extracorporeal cardiopulmonary resuscitation (ECPR) has been considered a potential treatment for refractory cardiac arrest after failure of conventional cardiopulmonary resuscitation (CCPR), the benefit of ECPR in refractory OHCA remains uncertain.
METHODS: In this retrospective cohort study, we included patients with refractory OHCA who visited the Emergency Department of the Aerospace Center Hospital between January 2018 and April 2023. We divided the patients into the ECPR Group and the CCPR Group. The primary endpoint of the study was the neurological function of the patients in both groups 3 months after the cardiac arrest. We used propensity score matching to reduce selection bias and identified factors associated with good neurological function when OHCA was treated with ECPR by performing univariate and multivariate correlation analyses on surviving patients with good neurological function in the ECPR group.
RESULTS: During the study period, we enrolled 133 patients, consisting of 33 in the ECPR group and 100 in the CCPR group. The survival rate of patients with good neurological function at discharge was 18.2% (6/33 cases) in the ECPR group and 9% (9/100 cases) in the CCPR group, p = .20. Three months after discharge, the survival rate of patients with good neurological function was 15.2% (5/33 cases) in the ECPR group and 8% (8/100 cases) in the CCPR group, p = .31. Using propensity score matching, we identified 22 pairs of patients for further analysis. Among these, 3 months after discharge, the survival rate of patients with good neurological function was 13.6% (3/22 cases) in the ECPR group and 4.5% (1/22 cases) in the CCPR group, p = .61, and the survival rate at discharge was 18.2% (4/22 cases) in the ECPR group and 4.5% (1/22 cases) in the CCPR group, p = .34. The univariate analysis of patients with good neurological function in the ECPR group showed that time without perfusion, hypoperfusion time, and PCI treatment were associated factors affecting the prognosis of neurological function in patients, while multivariate analysis showed that hypoperfusion time was independently associated with good neurological function, with an OR (95% CI) of 1.06 (1.00-1.14) and p = .05.
CONCLUSIONS: Our findings suggested that ECPR failed to significantly improve neurological outcome in patients with refractory OHCA; however, the small sample size in this study may be insufficient to detect clinically relevant differences. In addition, hypoperfusion time may be a key predictive factor in identifying candidates for ECPR.

UNASSIGNED: Extracorporeal cardiopulmonary resuscitation (E-CPR) plays an indispensable role when resuscitation fails; however, extracorporeal life support (ECLS) in infants is different from that in adults. The objective of this study was to evaluate the outcomes of E-CPR in infants.
UNASSIGNED: A single-center retrospective study was conducted, analyzing 51 consecutive patients (age <1 year) who received E-CPR for in-hospital cardiac arrest between 2010 and 2021.
UNASSIGNED: The median age and body weight was 51 days (interquartile range [IQR], 17-111 days) and 3.4 kg (IQR, 2.9-5.1 kg), respectively. The cause of arrest was cardiogenic in 45 patients (88.2%), and 48 patients (94.1%) had congenital cardiac anomalies. The median conventional cardiopulmonary resuscitation (C-CPR) time before the initiation of ECLS was 77 minutes (IQR, 61-103 minutes) and duration of ECLS was 7 days (IQR, 3-12 days). There were 36 in-hospital deaths (70.6%), and another patient survived after heart transplantation. In the multivariate analysis, single-ventricular physiology (odds ratio [OR], 5.05; p=0.048), open sternum status (OR, 8.69; p=0.013), and C-CPR time (OR, 1.47 per 10 minutes; p=0.021) were significant predictors of in-hospital mortality. In a receiver operating characteristic curve, the optimal cut-off of C-CPR time was 70.5 minutes. The subgroup with early E-CPR (C-CPR time <70.5 minutes) showed a tendency for lower in-hospital mortality tendency (54.5% vs. 82.8%, p=0.060), albeit not statistically significant.
UNASSIGNED: If resuscitation fails in an infant, E-CPR could be a life-saving option. It is crucial to improve C-CPR quality and shorten the time before ECLS initiation.

UNASSIGNED: Pediatric out-of-hospital cardiac arrests (OHCAs) are frequently associated with a respiratory etiology. Despite the high proportion of preschool children with OHCAs, very few studies on this special population exist. This study characterizes the epidemiologic features of preschool pediatric OHCAs and analyzes the advantage of conventional (ventilations with chest compressions) bystander cardiopulmonary resuscitation (CPR) over compression-only bystander CPR (BCPR) on the one-month post-event neurological status of the patient.
UNASSIGNED: Japanese nationwide databases for all ambulance transport events and OHCAs occurring during a 4-year period between 2016 and 2019 were combined, totalling 3,608 patient events. Children ≤6-years-old were included; physician- and EMS-witnessed events, no prehospital resuscitation effort events, and neonatal patient events were excluded. Neurologically favorable 1-month survival rates were compared among groups using univariate and multivariate analyses before and after propensity score matching.
UNASSIGNED: From the combined database, 2,882 pediatric OHCAs meeting selection criteria were categorized as no BCPR (984), compression-only BCPR (1,428), and conventional BCPR (470). The proportion of bystander-witnessed cases was low (22.3%). Most OHCA witnesses were family members (88.5%), and most OHCAs occurred at home (88.0%). The neurologically favorable 1-month survival rates were: no BCPR 2.4%, compression only, 3.2%, and conventional 6.6% (P < 0.01). Multivariate logistic regression analysis before and after matching showed that conventional BCPR was associated with higher neurologically favorable 1-month survival than compression-only BCPR. Subgroup analyses after matching demonstrated that conventional BCPR was associated with better outcomes in nonmedical (adjusted odds ratio; 95% confidence interval, 2.83; 1.09-7.32) and unwitnessed OHCA cases (3.42; 1.09-10.8).
UNASSIGNED: Conventional CPR is rarely performed by bystanders in preschool pediatric OHCA. However, conventional BCPR results in neurologically favorable outcomes in nonmedical and unwitnessed cases.

Hyperoxia has been associated with adverse outcomes in post cardiac arrest (CA) patients. Study-objective was to examine the association between hyperoxia and 30-day mortality in a mixed cohort of two different modes of Cardiopulmonary Resuscitation (CPR): Extracorporeal (ECPR) vs. Conventional (CCPR).
In this retrospective cohort study of CA patients admitted to a tertiary level CA centre in Australia (over a 6.5-year time period) mean arterial oxygen levels (PaO2) and episodes of extreme hyperoxia (maximum of mean PaO2 ≥ 300 mmHg) were analysed over the first 8 days post CA.
One hundred and sixty-nine post CA patients were assessed (ECPR n = 79 / CCPR n = 90). Mean PaO2-levels were higher in the ECPR vs CCPR group (211 mmHg ± 58.4 vs 119 mmHg ± 18.1; p < 0.0001) as was the proportion with at least one episode of extreme hyperoxia (74.7% vs 16.7%; p < 0.001). After adjusting for confounders and the mode of CPR any episode of extreme hyperoxia was independently associated with a 2.52-fold increased risk of 30-day mortality (OR: 2.52, 95% CI: 1.06-5.98; p = 0.036).
We found extreme hyperoxia was more common in ECPR patients in the first 8 days post CA and independently associated with higher 30-day mortality, irrespective of the CPR-mode.

UNASSIGNED: The aim of this study was to analyze the effect of extracorporeal cardiopulmonary resuscitation on survival and neurological outcomes in in-hospital cardiac arrest patients.
UNASSIGNED: Between January 2018 and December 2020, a total of 22 patients (17 males, 5 females; mean age: 52.8±9.0 years; range, 32 to 70 years) treated with extracorporeal cardiopulmonary resuscitation using veno-arterial extracorporeal membrane oxygenation support for in-hospital cardiac arrest after acute coronary syndrome were retrospectively analyzed. The patients were divided into two groups as those weaned (n=13) and non-weaned (n=9) from the veno-arterial extracorporeal membrane oxygenation. Demographic data of the patients, heart rhythms at the beginning of conventional cardiopulmonary resuscitation, the angiographic and interventional results, survival and neurological outcomes of the patients before and after extracorporeal cardiopulmonary resuscitation were recorded.
UNASSIGNED: There was no significant difference between the groups in terms of comorbidity and baseline laboratory test values. The underlying rhythm was ventricular fibrillation in 92% of the patients in the weaned group and there was no cardiac rhythm in 67% of the patients in the non-weaned group (p=0.125). The recovery in the mean left ventricular ejection fraction was significantly evident in the weaned group (36.5±12.7% vs. 21.1±7.4%, respectively; p=0.004). The overall wean rate from veno-arterial extracorporeal membrane oxygenation was 59.1%; however, the discharge rate from hospital of survivors without any neurological sequelae was 36.4%.
UNASSIGNED: In-hospital cardiac arrest is a critical emergency situation requiring instantly life-saving interventions through conventional cardiopulmonary resuscitation. If it fails, extracorporeal cardiopulmonary resuscitation should be initiated, regardless the underlying etiology or rhythm disturbances. An effective conventional cardiopulmonary resuscitation is mandatory to prevent brain and body hypoperfusion.

Extracorporeal cardiopulmonary resuscitation (ECPR) with extracorporeal membrane oxygenation is a more promising treatment for out-of-hospital cardiac arrest (OHCA) than conventional cardiopulmonary resuscitation (CCPR). However, previous studies that compared ECPR and CCPR included mixed groups of patients with or without target temperature management (TTM). In this study, we compared the neurological outcomes of OHCA between ECPR and CCPR with TTM in all patients. We performed retrospective subanalyses of the Japanese Association for Acute Medicine OHCA registry. Witnessed adult cases of cardiogenic OHCA treated with TTM were eligible for this study. We used univariate and multivariable analyses in all eligible patients to compare the neurological outcomes after ECPR or CCPR. We also conducted propensity score analyses of all patients and according to the interval from witnessed OHCA to reaching the target temperature (IWT) of ≤600, ≤480, ≤360, ≤240, and ≤120 minutes. We analyzed 1146 cases. The propensity score analysis did not show a significant difference in favorable neurological outcomes (defined as a Glasgow-Pittsburgh Cerebral Performance Category of 1-2 at 1 month after collapse) between EPCR and CCPR (odds ratio: OR 4.683 [95% confidence interval: CI 0.859-25.535], p = 0.747). However, ECPR was associated with more favorable neurological outcomes in patients with IWT of ≤600 minutes (OR 7.089 [95% CI 1.091-46.061], p = 0.406), ≤480 minutes (OR 10.492 [95% CI 1.534-71.773], p = 0.0168), ≤360 minutes (OR 17.573 [95% CI 2.486-124.233], p = 0.0042), ≤240 minutes (OR 38.908 [95% CI 5.045-300.089], p = 0.0005), and ≤120 minutes (OR 200.390 [95% CI 23.730-1692.211], p < 0.001). This study revealed significant differences in the neurological outcomes between ECPR and CCPR in patients with TTM whose IWT was ≤600 minutes.

The objectives of this study were to 1) identify the risk factors for predicting re-arrest and 2) determine whether extracorporeal cardiopulmonary resuscitation results in better outcomes than conventional cardiopulmonary resuscitation for managing re-arrest in out-of-hospital cardiac arrest patients.
This retrospective analysis was based on a prospective cohort. We included adult patients with non-traumatic out-of-hospital cardiac arrest who achieved a survival event. The primary measurement was re-arrest, defined as recurrent cardiac arrest within 24 hours after survival event. Multiple logistic regression analysis was used to predict re-arrest. Subgroup analysis was performed to evaluate the effect of extracorporeal cardiopulmonary resuscitation on the survival to discharge in out-of-hospital cardiac arrest patients who experienced re-arrest.
Of 534 patients suitable for inclusion, 203 (38.0%) were enrolled in the re-arrest group. Old age, prolonged advanced cardiac life support duration and the presence of hypotension at 0 hours after survival event were independent variables predicting re-arrest. In the re-arrest group, the extracorporeal cardiopulmonary resuscitation group (n = 25) showed better outcomes than the conventional cardiopulmonary resuscitation group. However, multiple logistic regression for predicting survival to discharge revealed that extracorporeal cardiopulmonary resuscitation was not an independent factor. Multiple logistic regression revealed that a hypotensive state at re-arrest was an independent risk factor for survival.
Alternative methods that reduce the advanced cardiac life support duration should be considered to prevent re-arrest and attain good outcomes in out-of-hospital cardiac arrest patients. Extracorporeal cardiopulmonary resuscitation for re-arrest tended to show a good outcome compared to conventional cardiopulmonary resuscitation for re-arrest. Avoiding or immediately correcting hypotension may prevent re-arrest and improve the outcome of re-arrested patients.