Extracorporeal cardiopulmonary resuscitation for cardiac arrest: A systematic review

  • Mathias J. Holmberg
    Affiliations
    Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Bygning J, Plan 1, 8200 Aarhus N, Denmark

    Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA
    Search for articles by this author
  • Guillaume Geri
    Affiliations
    Medical Intensive Care Unit, Assistance Publique Hôpitaux de Paris, Ambroise Paré Hospital, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France

    Versailles Saint Quentin University, INSERM UMR1018, Team 5 Kidney & Heart, 78000 Versailles, France
    Search for articles by this author
  • Sebastian Wiberg
    Affiliations
    Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA

    Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
    Search for articles by this author
  • Anne-Marie Guerguerian
    Affiliations
    Department of Critical Care Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada
    Search for articles by this author
  • Michael W. Donnino
    Affiliations
    Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA

    Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA
    Search for articles by this author
  • Jerry P. Nolan
    Affiliations
    Bristol Medical School, University of Bristol, 69 St Michael’s Hill, Bristol BS2 8DZ, UK
    Search for articles by this author
  • Charles D. Deakin
    Affiliations
    NIHR Southampton Respiratory Biomedical Research Unit, Southampton, SO16 6YD, UK
    Search for articles by this author
  • Lars W. Andersen
    Correspondence
    Corresponding author: Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Bygning J, Plan 1, 8200 Aarhus N, Denmark.
    Affiliations
    Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Bygning J, Plan 1, 8200 Aarhus N, Denmark

    Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA
    Search for articles by this author
  • for the International Liaison Committee on Resuscitation’s (ILCOR) Advanced Life Support and Pediatric Task Forces

      Abstract

      Aim

      To assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual or mechanical cardiopulmonary resuscitation (CPR), for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) in adults and children.

      Methods

      The PRISMA guidelines were followed. We searched Medline, Embase, and Evidence-Based Medicine Reviews for randomized clinical trials and observational studies published before May 22, 2018. The population included adult and pediatric patients with OHCA and IHCA of any origin. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Outcomes included short-term and long-term survival and favorable neurological outcome.

      Results

      We included 25 observational studies, of which 15 studies were in adult OHCA, 7 studies were in adult IHCA, and 3 studies were in pediatric IHCA. There were no studies in pediatric OHCA. No randomized trials were included. Results from individual studies were largely inconsistent, although several studies in adult and pediatric IHCA were in favor of ECPR. The risk of bias for individual studies was overall assessed to be critical, with confounding being the primary source of bias. The overall quality of evidence was assessed to be very low. Heterogeneity across studies precluded any meaningful meta-analyses.

      Conclusions

      There is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA in adults and children. The quality of evidence across studies is very low.

      Keywords

      To read this article in full you will need to make a payment
      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Conrad S.A.
        • Broman L.M.
        • Taccone F.S.
        • Lorusso R.
        • Malfertheiner M.V.
        • Pappalardo F.
        • et al.
        The extracorporeal life support organization Maastricht treaty for nomenclature in extracorporeal life support. A position paper of the extracorporeal life support organization.
        Am J Respir Crit Care Med. 2018; (Epub ahead of print)
        • Link M.S.
        • Berkow L.C.
        • Kudenchuk P.J.
        • Halperin H.R.
        • Hess E.P.
        • Moitra V.K.
        • et al.
        Part 7: adult advanced cardiovascular life support: 2015 American Heart Association Guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2015; 132: S444-64
        • de Caen A.R.
        • Berg M.D.
        • Chameides L.
        • Gooden C.K.
        • Hickey R.W.
        • Scott H.F.
        • et al.
        Part 12: pediatric advanced life support: 2015 American Heart Association Guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2015; 132: S526-42
        • Soar J.
        • Nolan J.P.
        • Böttiger B.W.
        • Perkins G.D.
        • Lott C.
        • Carli P.
        • et al.
        European Resuscitation Council Guidelines for resuscitation 2015: section 3. Adult advanced life support.
        Resuscitation. 2015; 95: 100-147
        • Maconochie I.K.
        • Bingham R.
        • Eich C.
        • López-Herce J.
        • Rodríguez-Núñez A.
        • Rajka T.
        • et al.
        European Resuscitation Council Guidelines for Resuscitation 2015: Section 6. Paediatric life support.
        Resuscitation. 2015; 95: 223-248
        • Abrams D.
        • Garan A.R.
        • Abdelbary A.
        • Bacchetta M.
        • Bartlett R.H.
        • Beck J.
        • et al.
        Position paper for the organization of ECMO programs for cardiac failure in adults.
        Intensive Care Med. 2018;
        • Riggs K.R.
        • Becker L.B.
        • Sugarman J.
        Ethics in the use of extracorporeal cardiopulmonary resuscitation in adults.
        Resuscitation. 2015; 91: 73-75
        • Richardson A.S.
        • Schmidt M.
        • Bailey M.
        • Pellegrino V.A.
        • Rycus P.T.
        • Pilcher D.V.
        ECMO Cardio-Pulmonary Resuscitation (ECPR), trends in survival from an international multicentre cohort study over 12-years.
        Resuscitation. 2017; 112: 34-40
        • McCarthy F.H.
        • McDermott K.M.
        • Kini V.
        • Gutsche J.T.
        • Wald J.W.
        • Xie D.
        • et al.
        Trends in U.S. Extracorporeal membrane oxygenation use and outcomes: 2002–2012.
        Semin Thorac Cardiovasc Surg. 2015; 27: 81-88
        • Paden M.L.
        • Rycus P.T.
        • Thiagarajan R.R.
        • Registry E.
        Update and outcomes in extracorporeal life support.
        Semin Perinatol. 2014; 38: 65-70
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • Group P.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; 339: b2535
        • McHugh M.L.
        Interrater reliability: the kappa statistic.
        Biochem Med (Zagreb). 2012; 22: 276-282
        • Sterne J.A.
        • Hernán M.A.
        • Reeves B.C.
        • Savović J.
        • Berkman N.D.
        • Viswanathan M.
        • et al.
        ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions.
        BMJ. 2016; 355: i4919
        • Higgins J.
        • Green S.
        Cochrane handbook for systematic reviews of interventions.
        2011 (Version 5.1.0. [Updated March 2011])
        • Guyatt G.H.
        • Oxman A.D.
        • Vist G.E.
        • Kunz R.
        • Falck-Ytter Y.
        • Alonso-Coello P.
        • et al.
        GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
        BMJ. 2008; 336: 924-926
        • Agostinucci J.M.
        • Ruscev M.
        • Galinski M.
        • Gravelo S.
        • Petrovic T.
        • Carmeaux C.
        • et al.
        Out-of-hospital use of an automated chest compression device: facilitating access to extracorporeal life support or non-heart-beating organ procurement.
        Am J Emerg Med. 2011; 29: 1169-1172
        • Cesana F.
        • Avalli L.
        • Garatti L.
        • Coppo A.
        • Righetti S.
        • Calchera I.
        • et al.
        Effects of extracorporeal cardiopulmonary resuscitation on neurological and cardiac outcome after ischaemic refractory cardiac arrest.
        Eur Heart J Acute Cardiovasc Care. 2017; (p. 2048872617737041)
        • Choi D.H.
        • Kim Y.J.
        • Ryoo S.M.
        • Sohn C.H.
        • Ahn S.
        • Seo D.W.
        • et al.
        Extracorporeal cardiopulmonary resuscitation among patients with out-of-hospital cardiac arrest.
        Clin Exp Emerg Med. 2016; 3: 132-138
        • Hase M.
        • Tsuchihashi K.
        • Fujii N.
        • Nishizato K.
        • Kokubu N.
        • Nara S.
        • et al.
        Early defibrillation and circulatory support can provide better long-term outcomes through favorable neurological recovery in patients with out-of-hospital cardiac arrest of cardiac origin.
        Circ J. 2005; 69: 1302-1307
        • Kim S.J.
        • Jung J.S.
        • Park J.H.
        • Park J.S.
        • Hong Y.S.
        • Lee S.W.
        An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study.
        Crit Care. 2014; 18: 535
        • Lee S.H.
        • Jung J.S.
        • Lee K.H.
        • Kim H.J.
        • Son H.S.
        • Sun K.
        Comparison of extracorporeal cardiopulmonary resuscitation with conventional cardiopulmonary resuscitation: is extracorporeal cardiopulmonary resuscitation beneficial?.
        Korean J Thorac Cardiovasc Surg. 2015; 48: 318-327
        • Maekawa K.
        • Tanno K.
        • Hase M.
        • Mori K.
        • Asai Y.
        Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis.
        Crit Care Med. 2013; 41: 1186-1196
        • Poppe M.
        • Weiser C.
        • Holzer M.
        • Sulzgruber P.
        • Datler P.
        • Keferbock M.
        • et al.
        The incidence of “load&go” out-of-hospital cardiac arrest candidates for emergency department utilization of emergency extracorporeal life support: a one-year review.
        Resuscitation. 2015; 91: 131-136
        • Sakamoto T.
        • Morimura N.
        • Nagao K.
        • Asai Y.
        • Yokota H.
        • Nara S.
        • et al.
        Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study.
        Resuscitation. 2014; 85: 762-768
        • Schober A.
        • Sterz F.
        • Herkner H.
        • Wallmueller C.
        • Weiser C.
        • Hubner P.
        • et al.
        Emergency extracorporeal life support and ongoing resuscitation: a retrospective comparison for refractory out-of-hospital cardiac arrest.
        Emerg Med J. 2017; 34: 277-281
        • Siao F.Y.
        • Chiu C.C.
        • Chiu C.W.
        • Chen Y.C.
        • Chen Y.L.
        • Hsieh Y.K.
        • et al.
        Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation.
        Resuscitation. 2015; 92: 70-76
        • Tanno K.
        • Itoh Y.
        • Takeyama Y.
        • Nara S.
        • Mori K.
        • Asai Y.
        Utstein style study of cardiopulmonary bypass after cardiac arrest.
        Am J Emerg Med. 2008; 26: 649-654
        • Venturini J.M.
        • Retzer E.
        • Estrada J.R.
        • Friant J.
        • Beiser D.
        • Edelson D.
        • et al.
        Mechanical chest compressions improve rate of return of spontaneous circulation and allow for initiation of percutaneous circulatory support during cardiac arrest in the cardiac catheterization laboratory.
        Resuscitation. 2017; 115: 56-60
        • Yannopoulos D.
        • Bartos J.A.
        • Martin C.
        • Raveendran G.
        • Missov E.
        • Conterato M.
        • et al.
        Minnesota resuscitation consortium’s advanced perfusion and reperfusion cardiac life support strategy for out-of-Hospital refractory ventricular fibrillation.
        J Am Heart Assoc. 2016; 5
        • Yannopoulos D.
        • Bartos J.A.
        • Raveendran G.
        • Conterato M.
        • Frascone R.J.
        • Trembley A.
        • et al.
        Coronary artery disease in patients with out-of-Hospital refractory ventricular fibrillation cardiac arrest.
        J Am Coll Cardiol. 2017; 70: 1109-1117
        • Blumenstein J.
        • Leick J.
        • Liebetrau C.
        • Kempfert J.
        • Gaede L.
        • Gross S.
        • et al.
        Extracorporeal life support in cardiovascular patients with observed refractory in-hospital cardiac arrest is associated with favourable short and long-term outcomes: a propensity-matched analysis.
        Eur Heart J Acute Cardiovasc Care. 2016; 5: 13-22
        • Chen Y.S.
        • Lin J.W.
        • Yu H.Y.
        • Ko W.J.
        • Jerng J.S.
        • Chang W.T.
        • et al.
        Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis.
        Lancet. 2008; 372: 554-561
        • Cho Y.H.
        • Kim W.S.
        • Sung K.
        • Jeong D.S.
        • Lee Y.T.
        • Park P.W.
        • et al.
        Management of cardiac arrest caused by acute massive pulmonary thromboembolism: importance of percutaneous cardiopulmonary support.
        ASAIO J. 2014; 60: 280-283
        • Chou T.H.
        • Fang C.C.
        • Yen Z.S.
        • Lee C.C.
        • Chen Y.S.
        • Ko W.J.
        • et al.
        An observational study of extracorporeal CPR for in-hospital cardiac arrest secondary to myocardial infarction.
        Emerg Med J. 2014; 31: 441-447
        • Lin J.W.
        • Wang M.J.
        • Yu H.Y.
        • Wang C.H.
        • Chang W.T.
        • Jerng J.S.
        • et al.
        Comparing the survival between extracorporeal rescue and conventional resuscitation in adult in-hospital cardiac arrests: propensity analysis of three-year data.
        Resuscitation. 2010; 81: 796-803
        • Shin T.G.
        • Choi J.H.
        • Jo I.J.
        • Sim M.S.
        • Song H.G.
        • Jeong Y.K.
        • et al.
        Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: a comparison with conventional cardiopulmonary resuscitation.
        Crit Care Med. 2011; 39: 1-7
        • Shin T.G.
        • Jo I.J.
        • Sim M.S.
        • Song Y.B.
        • Yang J.H.
        • Hahn J.Y.
        • et al.
        Two-year survival and neurological outcome of in-hospital cardiac arrest patients rescued by extracorporeal cardiopulmonary resuscitation.
        Int J Cardiol. 2013; 168: 3424-3430
        • Lasa J.J.
        • Rogers R.S.
        • Localio R.
        • Shults J.
        • Raymond T.
        • Gaies M.
        • et al.
        Extracorporeal Cardiopulmonary Resuscitation (E-CPR) during pediatric in-hospital cardiopulmonary arrest is associated with improved survival to discharge: a report from the American Heart Association’s Get With The Guidelines-Resuscitation (GWTG-R) registry.
        Circulation. 2016; 133: 165-176
        • Odegard K.C.
        • Bergersen L.
        • Thiagarajan R.
        • Clark L.
        • Shukla A.
        • Wypij D.
        • et al.
        The frequency of cardiac arrests in patients with congenital heart disease undergoing cardiac catheterization.
        Anesth Analg. 2014; 118: 175-182
        • Ortmann L.
        • Prodhan P.
        • Gossett J.
        • Schexnayder S.
        • Berg R.
        • Nadkarni V.
        • et al.
        Outcomes after in-hospital cardiac arrest in children with cardiac disease: a report from Get With the Guidelines--Resuscitation.
        Circulation. 2011; 124: 2329-2337
        • Moler F.W.
        • Meert K.
        • Donaldson A.E.
        • Nadkarni V.
        • Brilli R.J.
        • Dalton H.J.
        • et al.
        In-hospital versus out-of-hospital pediatric cardiac arrest: a multicenter cohort study.
        Crit Care Med. 2009; 37: 2259-2267
        • Fredriksson M.
        • Aune S.
        • Bång A.
        • Thorén A.B.
        • Lindqvist J.
        • Karlsson T.
        • et al.
        Cardiac arrest outside and inside hospital in a community: mechanisms behind the differences in outcome and outcome in relation to time of arrest.
        Am Heart J. 2010; 159: 749-756
        • Engsig M.
        • Søholm H.
        • Folke F.
        • Gadegaard P.J.
        • Wiis J.T.
        • Molin R.
        • et al.
        Similar long-term survival of consecutive in-hospital and out-of-hospital cardiac arrest patients treated with targeted temperature management.
        Clin Epidemiol. 2016; 8: 761-768
        • Moskowitz A.
        • Holmberg M.J.
        • Donnino M.W.
        • Berg K.M.
        In-hospital cardiac arrest: are we overlooking a key distinction?.
        Curr Opin Crit Care. 2018; 24: 151-157
        • Singer B.
        • Reynolds J.C.
        • Lockey D.J.
        • O’Brien B.
        Pre-hospital extra-corporeal cardiopulmonary resuscitation.
        Scand J Trauma Resusc Emerg Med. 2018; 26: 21
        • Andersen L.W.
        • Grossestreuer A.V.
        • Donnino M.W.
        “Resuscitation time bias”-a unique challenge for observational cardiac arrest research.
        Resuscitation. 2018; 125: 79-82
        • Schisterman E.F.
        • Cole S.R.
        • Platt R.W.
        Overadjustment bias and unnecessary adjustment in epidemiologic studies.
        Epidemiology. 2009; 20: 488-495
        • Harvey M.J.
        • Gaies M.G.
        • Prosser L.A.
        U.S. and International In-Hospital Costs of Extracorporeal Membrane Oxygenation: a Systematic Review.
        Appl Health Econ Health Policy. 2015; 13: 341-357
        • D’Arrigo S.
        • Cacciola S.
        • Dennis M.
        • Jung C.
        • Kagawa E.
        • Antonelli M.
        • et al.
        Predictors of favourable outcome after in-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation: a systematic review and meta-analysis.
        Resuscitation. 2017; 121: 62-70
        • Debaty G.
        • Babaz V.
        • Durand M.
        • Gaide-Chevronnay L.
        • Fournel E.
        • Blancher M.
        • et al.
        Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis.
        Resuscitation. 2017; 112: 1-10
        • Yuan-Hsi T.
        • Meng-Yu W.
        • Feng-Chun T.
        • Hai-Jing C.
        • Pyng Jing L.
        Costs associated with extracorporeal life support used in adults: a single-center study.
        Acta Cardiol Sin. 2011; 27: 221-228
        • St-Onge M.
        • Fan E.
        • Mégarbane B.
        • Hancock-Howard R.
        • Coyte P.C.
        Venoarterial extracorporeal membrane oxygenation for patients in shock or cardiac arrest secondary to cardiotoxicant poisoning: a cost-effectiveness analysis.
        J Crit Care. 2015; 30 (p. 437.e7-14)
        • Mahle W.T.
        • Forbess J.M.
        • Kirshbom P.M.
        • Cuadrado A.R.
        • Simsic J.M.
        • Kanter K.R.
        Cost-utility analysis of salvage cardiac extracorporeal membrane oxygenation in children.
        J Thorac Cardiovasc Surg. 2005; 129: 1084-1090