Simon Bourcier1, Cyrielle Desnos1, Marina Clément2, Guillaume Hékimian1, Nicolas Bréchot3, Fabio Silvio Taccone4, Mirko Belliato5, Federico Pappalardo6, Lars Mikael Broman7, Maximilian Valentin Malfertheiner8, Dirk Lunz9, Matthieu Schmidt3, Pascal Leprince10, Alain Combes3, Guillaume Lebreton10, Charles-Edouard Luyt11. 1. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Médecine Intensive Réanimation, Paris, France. 2. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Cardiovascular and Thoracic Surgery, Paris, France. 3. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Médecine Intensive Réanimation, Paris, France; Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France. 4. Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Cliniques Universitaires de Bruxelles (CUB) Erasme, Brussels, Belgium. 5. UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione 2 Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy. 6. Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Palermo, Italy. 7. ECMO Centre Karolinska, Karolinska University Hospital, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden. 8. Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Medical Center Regensburg, Regensburg, Germany. 9. Department of Anesthesiology and Intensive Care, University Hospital Regensburg, Regensburg, Germany. 10. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Cardiovascular and Thoracic Surgery, Paris, France; Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France. 11. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Médecine Intensive Réanimation, Paris, France; Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France. Electronic address: charles-edouard.luyt@aphp.fr.
Abstract
BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for refractory cardiac arrest, but its high mortality has raised questions about patient selection. No selection criteria have been proposed for patients experiencing in-hospital cardiac arrest. We aimed to identify selection criteria available at the time ECPR was considered for patients with in-hospital cardiac arrest. We analyzed data of in-hospital cardiac arrest patients undergoing ECPR in our extracorporeal membrane oxygenation (ECMO) center (March 2007 to March 2019). Intensive care unit (ICU) and 1-year survival post-hospital discharge were assessed. Factors associated with ICU survival before ECPR were investigated. An external validation cohort from a previous multicenter study was used to validate our results. RESULTS: Among the 137 patients (67.9% men; median [IQR] age, 54 [43-62] years; low-flow duration, 45 [30-70] min) requiring ECPR, 32.1% were weaned-off ECMO. Their respective ICU- and 1-year survival rates were 21.9% and 19%. Most 1-year survivors had favorable neurological outcomes (cerebral performance category score 1 or 2). ICU survivors compared to nonsurvivors, respectively, were more likely to have a shockable initial rhythm (53.3% versus 24.3%; P < 0.01), a shorter median (IQR) low-flow time (30 (25-53) versus 50 (35-80) min, P < 0.01) and they more frequently underwent a subsequent intervention (63.3% versus 26.2%, P < 0.01). The algorithm obtained by combining age, initial rhythm and low-flow duration discriminated between patient groups with very different survival probabilities in the derivation and validation cohorts. CONCLUSION: Survival of ECPR-managed in-hospital cardiac arrest patients in this cohort was poor but hospital survivors' 1-year neurological outcomes were favorable. When deciding whether or not to use ECPR, the combination of age, initial rhythm and low-flow duration can improve patient selection.
BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for refractory cardiac arrest, but its high mortality has raised questions about patient selection. No selection criteria have been proposed for patients experiencing in-hospital cardiac arrest. We aimed to identify selection criteria available at the time ECPR was considered for patients with in-hospital cardiac arrest. We analyzed data of in-hospital cardiac arrest patients undergoing ECPR in our extracorporeal membrane oxygenation (ECMO) center (March 2007 to March 2019). Intensive care unit (ICU) and 1-year survival post-hospital discharge were assessed. Factors associated with ICU survival before ECPR were investigated. An external validation cohort from a previous multicenter study was used to validate our results. RESULTS: Among the 137 patients (67.9% men; median [IQR] age, 54 [43-62] years; low-flow duration, 45 [30-70] min) requiring ECPR, 32.1% were weaned-off ECMO. Their respective ICU- and 1-year survival rates were 21.9% and 19%. Most 1-year survivors had favorable neurological outcomes (cerebral performance category score 1 or 2). ICU survivors compared to nonsurvivors, respectively, were more likely to have a shockable initial rhythm (53.3% versus 24.3%; P < 0.01), a shorter median (IQR) low-flow time (30 (25-53) versus 50 (35-80) min, P < 0.01) and they more frequently underwent a subsequent intervention (63.3% versus 26.2%, P < 0.01). The algorithm obtained by combining age, initial rhythm and low-flow duration discriminated between patient groups with very different survival probabilities in the derivation and validation cohorts. CONCLUSION: Survival of ECPR-managed in-hospital cardiac arrest patients in this cohort was poor but hospital survivors' 1-year neurological outcomes were favorable. When deciding whether or not to use ECPR, the combination of age, initial rhythm and low-flow duration can improve patient selection.