Controversies in Extracorporeal Cardiopulmonary Resuscitation

Abstract

Extracorporeal cardiopulmonary resuscitation (ECPR) is the emergent deployment of VA-ECMO for refractory cardiac arrest. Observational and randomized trial data show that ECPR may improve outcomes compared to conventional CPR (CCPR), but many questions and controversies remain. Patient selection is a critical determinant of ECPR success. Most institutions implement inclusion/exclusion criteria, but risk scores may be more apt to correctly predict which patients are likely to benefit from ECPR. Good outcomes from ECPR occur more often in patients with an initially shockable rhythm, reversible etiology of arrest, evidence of effective CPR, and shorter durations of conventional CPR. Shorter total CPR duration is consistently associated with neurologically favorable survival, but optimal and upper limit timing at which the benefits of ECPR outweigh the risks continue to be delineated. Data are emerging regarding pre-hospital implementation of ECPR as a strategy to reduce low-flow time. Vascular access for ECPR can be challenging, particularly in the pediatric population. In adults, percutaneous cannulation of the femoral vessels under fluoroscopic guidance and performed by a small group of highly skilled operators may increase success rates and reduce complications. Data are limited regarding post-arrest care for the ECPR patient, particularly regarding temperature management and anticoagulation. Compared to other resource-intensive therapies, ECPR is cost-effective by modern standards.