Clinical paperPrevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates
Introduction
Despite advances in care, rates of return of spontaneous circulation (ROSC) and functionally favorable survival after out-of-hospital cardiac arrest (OHCA) remain unacceptably poor [1]. Adding extracorporeal support to conventional cardiopulmonary resuscitation (ECPR) is an appealing method to improve outcomes after OHCA [2], [3], [4], [5], [6]. Compared to conventional resuscitation, ECPR improves blood flow and oxygen delivery during pulselessness, delays irreversible end-organ damage, and may facilitate therapies such as coronary angiography or fibrinolysis that treat the inciting cause of OHCA [7].
Whether these physiological benefits improve survival and functional recovery remains uncertain. While overall survival in published observational series is excellent [2], [3], [4], [5], [6], clinical features that make patients attractive candidates for ECPR (e.g. shockable initial cardiac rhythm, witnessed cardiac arrest, bystander CPR) are also associated with favorable clinical outcomes [8], [9], [10]. Reflecting the low level of existing evidence, current guidelines provide weak recommendation for consideration of ECPR in select cases [11]. The potential benefit, ideal patient selection, and optimal logistics to operationalize ECPR can only be tested in rigorous clinical trials.
To inform the design of such a trial, we estimated the prevalence of ECPR-eligible subjects using a large, multi-center cohort of EMS-treated OHCA, and described their baseline outcomes with conventional resuscitation. We additionally characterized the time-dependent effects of resuscitation duration on patient outcomes and clinical factors that would affect decisions to use ECPR in order to determine the optimal therapeutic window for conversion from traditional resuscitation to ECPR. Finally, we performed subgroup analyses to determine if this therapeutic window differed for subjects with shockable and nonshockable initial cardiac rhythms
Section snippets
Data source
We examined de-identified data from the Resuscitation Outcomes Consortium (ROC) Prehospital Resuscitation using an IMpedance valve and Early versus Delayed (PRIMED) trial [12], [13]. Data were obtained from National Institutes of Health Biologic Specimen and Data Repository Information Coordinating Center (BioLINCC). Michigan State University IRB granted waiver of consent for this secondary analysis of a de-identified dataset. The original trial found no difference in outcomes across all
Results
Among a 24 million total catchment population covering 35,000 square miles, the PRIMED dataset captured 17,445 subjects and 11,368 had complete time and outcome data (Fig. 1). Using our hypothetical criteria, 1237 subjects (10.9%; 95% CI 10.3–11.5%) were eligible for ECPR and included in the final cohort. Of these, 778/1237 (63%) achieved ROSC, 466/1237 (38%) survived to hospital discharge, and 377/1237 (30%) survived to hospital discharge with mRS 0–3. Median interval from EMS dispatch to
Discussion
Clinical decision-making surrounding ECPR is fraught with issues of candidate selection, timing, and logistical considerations. ECPR is a resource-intensive therapy that should be rationally deployed in such a way to maximize the potential benefit to patients while minimizing unnecessary exposure to complications and costs. We found that among consecutive EMS-treated OHCA subjects eligible for enrollment in the PRIMED clinical trial, 11% would have been eligible for ECPR using conservative
Conclusions
In a North American, multi-center cohort of EMS-treated OHCA subjects, approximately 11% met inclusion criteria for ECPR. One-third of ECPR eligible subjects failed to achieve ROSC with conventional resuscitation, and half of those with ROSC died in the hospital or were discharged with poor neurologic outcome. The likelihood of ROSC and neurologically favorable survival both steadily declined over elapsed resuscitation to approach zero, and resuscitation duration was independently associated
Conflicts of interest
Reynolds: Nothing to disclose.
Grunau: Nothing to disclose.
Elmer: Dr. Elmer is funded by NHLBI5K12HL109068.
Rittenberger: Dr. Rittenberger is funded through the AHA Grant-in-Aid program. He has received travel reimbursement and honoraria from C. R. Bard.
Sawyer: Nothing to disclose.
Singer: Nothing to disclose.
Proudfoot: Nothing to disclose.
Kurz: Dr. Kurz is funded by NIH5U01DK096037 (Site PI); K23AG038548 (Site PI); R01GM101197 (Site PI); R01GM103799 (Site PI); American Heart Association; Society
Acknowledgements
None
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2017.05.024.