Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: 10-year experience in a metropolitan cardiac arrest centre in Milan, Italy

Introduction

Growing evidence supports extracorporeal cardiopulmonary resuscitation (ECPR) for refractory out-of-hospital cardiac arrest (OHCA) patients, especially in experienced centres. We present characteristics, treatments, and outcomes of patients treated with ECPR in a high-volume cardiac arrest centre in the metropolitan area of Milan, Italy and determine prognostic factors.

Methods

Refractory OHCA patients treated with ECPR between 2013 and 2022 at IRCCS San Raffaele Scientific Institute in Milan had survival and neurological outcome assessed at hospital discharge.

Results

Out of 307 consecutive OHCA patients treated with ECPR (95% witnessed, 66% shockable, low-flow 70 [IQR 58-81] minutes), 17% survived and 9.4% had favourable neurological outcome. Survival and favourable neurological outcome increased to 51% (OR = 8.7; 95% CI, 4.3-18) and 28% (OR = 6.3; 95% CI, 2.8-14) when initial rhythm was shockable and low-flow (time between CPR initiation and ROSC or ECMO flow) ≤60 minutes and decreased to 9.5% and 6.3% when low-flow exceeded 60 minutes (72% of patients). At multivariable analysis, shockable rhythm (aOR for survival = 2.39; 95% CI, 1.04-5.48), shorter low-flow (aOR = 0.95; 95% CI, 0.94-0.97), intermittent ROSC (aOR = 2.5; 95% CI, 1.2-5.6), and signs of life (aOR = 3.7; 95% CI, 1.5-8.7) were associated with better outcomes. Survival reached 10% after treating 104 patients (p for trend <0.001).

Conclusions

Patients with initial shockable rhythm, intermittent ROSC, signs of life, and low-flow ≤60 minutes had higher success of ECPR for refractory OHCA. Favourable outcomes were possible beyond 60 minutes of low-flow, especially with concomitant favourable prognostic factors. Outcomes improved as the case-volume increased, supporting treatment in high-volume cardiac arrest centres.

Coronary angiography findings in resuscitated and refractory out-of-hospital cardiac arrest: A systematic review and meta-analysis

INTRODUCTION

Coronary angiography (CAG) frequently reveals coronary artery disease (CAD) after out-of-hospital cardiac arrest (OHCA), but its use is not standardized and often reported in different subpopulations. This systematic review and meta-analysis accurately describes angiographic features in resuscitated and refractory OHCA.

METHODS

PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched up to October 31, 2022. Studies reporting coronary angiography findings after OHCA were considered eligible. The primary outcome was location and rate of coronary lesions. Coronary angiography findings with 95% confidence intervals were pooled with a meta-analysis of proportion.

RESULTS

128 studies (62,845 patients) were included. CAG, performed in 69% (63-75%) of patients, found a significant CAD in 75% (70-79%), a culprit lesion in 63% (59-66%), and a multivessel disease in 46% (41-51%). Compared to patients with return of spontaneous circulation, refractory OHCA was associated with more severe CAD due to a higher rate of left main involvement (17% [12-24%] vs 5.7% [3.1-10%]; p = 0.002) and acute occlusion of left anterior descending artery (27% [17-39%] vs 15% [13-18%]; p = 0.02). Nonshockable patients without ST-elevation were those receiving CAG less frequently, despite significant disease in 54% (31-76%). Left anterior descending artery was the most frequently involved (34% [30-39%]).

CONCLUSIONS

Patients with OHCA have a high prevalence of significant CAD caused by acute and treatable coronary lesions. Refractory OHCA was associated with more severe coronary lesions. CAD was also present in patients with nonshockable rhythm and without ST elevation. However, heterogeneity of studies and selection of patients undergoing CAG limit the certainty of findings.

Refractory out-of-hospital cardiac arrest and extracorporeal cardiopulmonary resuscitation: A meta-analysis of randomized trials

BACKGROUND

In adults with refractory out-of-hospital cardiac arrest, when conventional cardiopulmonary resuscitation (CPR) alone does not achieve return of spontaneous circulation, extracorporeal CPR is attempted to restore perfusion and improve outcomes. Considering the contrasting findings of recent studies, we conducted a meta-analysis of randomized controlled trials to ascertain the effect of extracorporeal CPR on survival and neurological outcome.

METHODS

Pubmed via MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched up to February 3, 2023, for randomized controlled trials comparing extracorporeal CPR versus conventional CPR in adults with refractory out-of-hospital cardiac arrest. Survival with a favorable neurological outcome at the longest follow-up available was the primary outcome.

RESULTS

Among four randomized controlled trials included, extracorporeal CPR compared with conventional CPR increased survival with favorable neurological outcome at the longest follow-up available for all rhythms (59/220 [27%] vs. 39/213 [18%]; OR = 1.72; 95% CI, 1.09-2.70; p = 0.02; I²  = 26%; number needed to treat of 9), for initial shockable rhythms only (55/164 [34%] vs. 38/165 [23%]; OR = 1.90; 95% CI, 1.16-3.13; p = 0.01; I²  = 23%; number needed to treat of 7), and at hospital discharge or 30 days (55/220 [25%] vs. 34/212 [16%]; OR = 1.82; 95% CI, 1.13-2.92; p = 0.01; I²  = 0.0%). Overall survival at the longest follow-up available was similar (61/220 [25%] vs. 34/212 [16%]; OR = 1.82; 95% CI, 1.13-2.92; p = 0.59; I²  = 58%).

CONCLUSIONS

Extracorporeal CPR compared with conventional CPR increased survival with favorable neurological outcome in adults with refractory out-of-hospital cardiac arrest, especially when the initial rhythm was shockable.

REVIEW REGISTRATION

PROSPERO CRD42023396482.

British Cardiovascular Interventional Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 1: Pathway of Care

Out-of-hospital cardiac arrest (OHCA) affects 80,000 patients per year in the UK; despite improvements in care, survival to discharge remains lower than 10%. NHS England and several societies recommend all resuscitated OHCA patients be directly transferred to a cardiac arrest centre (CAC). However, evidence is limited that all patients benefit from transfer to a CAC, and there are significant organisational, logistic and financial implications associated with such change in policies. Furthermore, there is significant variability in interventional cardiovascular practices for OHCA. Accordingly, the British Cardiovascular Interventional Society established a multidisciplinary group to address variability in practice and provide recommendations for the development of cardiac networks. In this position statement, we recommend: the formal establishment of dedicated CACs; a pathway of conveyance to CACs; and interventional practice to standardise our approach. Further research is needed to understand the role of CACs and which interventions benefit patients with OHCA to support wide-scale changes in networks of care across the UK.

Joint British Societies' guideline on management of cardiac arrest in the cardiac catheter laboratory

More than 300 000 procedures are performed in cardiac catheter laboratories in the UK each year. The variety and complexity of percutaneous cardiovascular procedures have both increased substantially since the early days of invasive cardiology, when it was largely focused on elective coronary angiography and single chamber (right ventricular) permanent pacemaker implantation. Modern-day invasive cardiology encompasses primary percutaneous coronary intervention, cardiac resynchronisation therapy, complex arrhythmia ablation and structural heart interventions. These procedures all carry the risk of cardiac arrest.We have developed evidence-based guidelines for the management of cardiac arrest in adult patients in the catheter laboratory. The guidelines include recommendations which were developed by collaboration between nine professional and patient societies that are involved in promoting high-quality care for patients with cardiovascular conditions. We present a set of protocols which use the skills of the whole catheter laboratory team and which are aimed at achieving the best possible outcomes for patients who suffer a cardiac arrest in this setting. We identified six roles and developed a treatment algorithm which should be adopted during cardiac arrest in the catheter laboratory. We recommend that all catheter laboratory staff undergo regular training for these emergency situations which they will inevitably face.

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized and propensity score-matched studies

BACKGROUND

In selected patients with refractory out-of-hospital cardiac arrest, extracorporeal cardiopulmonary resuscitation represents a promising approach when conventional cardiopulmonary resuscitation fails to achieve return of spontaneous circulation. This systematic review and meta-analysis aimed to compare extracorporeal cardiopulmonary resuscitation to conventional cardiopulmonary resuscitation.

METHODS

We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials up to November 28, 2021, for randomized trials and observational studies reporting propensity score-matched data and comparing adults with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation with those treated with conventional cardiopulmonary resuscitation. The primary outcome was survival with favorable neurological outcome at the longest follow-up available. Secondary outcomes were survival at the longest follow-up available and survival at hospital discharge/30 days.

RESULTS

We included six studies, two randomized and four propensity score-matched studies. Patients treated with extracorporeal cardiopulmonary resuscitation had higher rates of survival with favorable neurological outcome (81/584 [14%] vs. 46/593 [7.8%]; OR = 2.11; 95% CI, 1.41-3.15; p < 0.001, number needed to treat 16) and of survival (131/584 [22%] vs. 102/593 [17%]; OR = 1.40; 95% CI, 1.05-1.87; p = 0.02) at the longest follow-up available compared with conventional cardiopulmonary resuscitation. Survival at hospital discharge/30 days was similar between the two groups (142/584 [24%] vs. 122/593 [21%]; OR = 1.26; 95% CI, 0.95-1.66; p = 0.10).

CONCLUSIONS

Evidence from randomized trials and propensity score-matched studies suggests increased survival and favorable neurological outcome in patients with refractory out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation. Large, multicentre randomized studies are still ongoing to confirm these findings.

Trends of the incidence and clinical outcomes of suicide-related out-of-hospital cardiac arrest in Korea: A 10-year nationwide observational study

BACKGROUND

The purpose of this study was to evaluate the characteristics and temporal trends of the incidence and survival outcomes of suicide-related out-of-hospital cardiac arrest (OHCA) according to the suicide attempt method during the past decade.

METHODS

A population-based observational study between 2009 and 2018 was conducted. EMS-treated suicide-related OHCAs were classified according to the suicide method into hanging, jumping, poisoning, asphyxia and drowning, and other trauma. The study outcomes were survival to discharge and good neurological outcome. The temporal trends of crude and age- and sex-standardized incidence per 100,000 person-years and standardized rates for outcomes were calculated using direct standardization methods. Predictors of survival to discharge were investigated using multivariable logistic regression.

RESULTS

From 2009 to 2018, the age- and sex-standardized incidence rate of suicide-related OHCA increased from 3.5 to 4.0 cases per 100,000 person-years. Of 21,720 eligible OHCAs, hanging (59.2%) was the most common suicide method, followed by jumping (21.3%), poisoning (14.9%), and asphyxia and drowning (3.5%). Although the standardized rates of survival to hospital discharge improved from 2.9% to 5.1% during the study period, good neurological outcome was not improved (from 0.7% to 1.0%). By suicide method, survival to discharge for the hanging group was increased, and good neurological outcome for the poisoning group showed improvement (both p-for-trend <0.05). Compared with hanging, other suicide methods were negatively associated with survival outcome.

CONCLUSION

The incidence of suicide-related OHCA has increased over the past decade in Korea, and survival outcomes are still very low. New interventions are needed to decrease the incidence and burden of suicide-related OHCAs.