J Extra Corpor Technol 2023 , 55 , 185 – 188 Ó The Author ( s ), published by EDP Sciences , 2023 https :// doi . org / 10.1051 / ject / 2023042
Available online at : ject . edpsciences . org
TECHNIQUE OR APPLICATION
Building an Extracorporeal Cardiopulmonary Resuscitation Program at a High-volume Extracorporeal Membrane Oxygenation Center
Peter C Michalakes ( BA ) 1 , Walter F DeNino ( MD ) 1 , 2 , Claire B Jara ( CCP ) 3 , Maxwell E Afari ( MD ) 1 , 4 , and Bram J Geller ( MD ) 1 , 5 ,*
1 Tufts University School of Medicine , Boston , MA , 02111 , USA 2 Department of Cardiac Surgery , Maine Medical Center , Portland , ME , 04102 , USA 3 Department of Cardiovascular Perfusion , Maine Medical Center , Portland , ME , 04102 , USA 4 Department of Advanced Heart Failure and Transplant Cardiology , Maine Medical Center , Portland , ME , 04102 , USA 5 Department of Cardiovascular Medicine , and Cardiovascular Critical Care Services , Maine Medical Center , Portland , ME , 04102 , USA
Received 9 August 2023 , Accepted 20 October 2023
Abstract – Extracorporeal Cardiopulmonary Resuscitation ( ECPR ) is an emerging approach to cardiac arrest . We present two contrasting cases from a high-volume extracorporeal membrane oxygenation ( ECMO ) center ( defined as greater than 30 ECMO cases per year ) without a 24 / 7 ECPR program to highlight how to establish an ECPR program with a focus on patient selection and outcome optimization . In one case , a patient presented with cardiac arrest during initial triage for chest pain within the emergency department , and in the other case , a patient experienced an out-ofhospital cardiac arrest with prolonged no-flow and low-flow time . Despite the lack of a 24 / 7 ECPR program at the presenting center , both patients received an ECPR evaluation , as both patients presented while all services necessary for ECMO cannulation were available . The in-hospital cardiac arrest patient was successfully cannulated for ECMO during cardiopulmonary resuscitation and survived with few complications . The out-of-hospital cardiac arrest patient was deemed a poor candidate for ECPR and expired soon after presentation . These two cases highlight the complex decision-making in ECPR and further illustrate how to create ECPR protocols at a high-volume ECMO center before resources are available for a 24 / 7 ECPR program .
Key words : Extracorporeal Cardiopulmonary Resuscitation ( ECPR ), Extracorporeal Membrane Oxygenation ( ECMO ), Cardiac arrest .
Overview
Extracorporeal cardiopulmonary resuscitation ( ECPR ) is an emerging approach for the management of both in-hospital cardiac arrest ( IHCA ) and out-of-hospital cardiac arrest ( OHCA ). Current evidence for ECPR is challenging to interpret given various selection criteria and protocol variations [ 1 ]. The ARREST trial in 2020 was a single-center randomized trial of patients with ventricular tachycardia / ventricular fibrillation ( VT / VF ) OHCA who were randomized to ECPR or standard of care . The trial was terminated early due to a significant survival benefit to ECPR [ 2 ]. Subsequently , a single-center randomized trial in Prague did not show a mortality benefit in OHCA from a presumed cardiac cause despite a bundle of care involving intra-arrest transport , ECPR , and immediate invasive assessment and treatment . The aforementioned study was
* Corresponding author : bram . geller @ mainehealth . org stopped early due to futility , though the study was performed as an intention-to-treat analysis and a substantial percentage of patients had a return of spontaneous circulation ( ROSC ) after randomization but prior to hospital arrival [ 3 ]. A secondary analysis of this trial found improved survival with ECPR for OHCA when patients who achieved ROSC before hospital arrival were separated from the standard of care and intervention groups [ 4 ]. Most recently , in 2023 , the INCEPTION trial found no significant differences in survival between ECPR and standard treatment for OHCA [ 5 ], lending greater uncertainty to the role of ECPR for OHCA . However , like the Prague trial , many patients in the INCEPTION trial also had ROSC after randomization and before hospital arrival . Notably , the ARREST and INCEPTION trials included patients only with shockable rhythms [ 2 , 5 , 6 ].
A meta-analysis in 2023 assessing ECPR for OHCA , including the above trials , confirmed the benefit of ECPR [ 6 ]. In this meta-analysis , while ECPR increased survival compared
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