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ECPR- Basic Concepts


Extra-Corporeal Cardiopulmonary Resuscitation (ECPR)

Introduction: What is ECPR?

Extracorporeal Cardiopulmonary Resuscitation (ECPR) is an advanced resuscitative technique that utilizes extracorporeal membrane oxygenation (ECMO) to provide circulatory and respiratory support in patients experiencing refractory cardiac arrest. Unlike conventional cardiopulmonary resuscitation (CPR), which relies on chest compressions and ventilation, ECPR involves the rapid establishment of veno-arterial ECMO to maintain perfusion to vital organs while treating the underlying cause of cardiac arrest. ECPR is primarily used in specialized centers with well-trained personnel and appropriate infrastructure, making it a resource-intensive intervention.

Background and History of ECPR

The concept of extracorporeal circulation has been evolving since the early 1950s, with Dr. John Gibbon’s development of the first successful heart-lung machine. In the 1970s, the use of ECMO for neonates with respiratory failure became widespread, and by the 1990s, ECMO began to be considered as an adjunct for cardiac arrest. The first reported cases of ECPR in adults emerged in the early 2000s, primarily in Japan and South Korea, where promising survival rates led to further clinical trials. Over the last two decades, multiple studies and guidelines have established ECPR as a viable option for select patients with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA).

Indications of ECPR

ECPR is considered for patients with cardiac arrest who meet the following criteria:

  • Refractory cardiac arrest (no return of spontaneous circulation despite conventional CPR for 10–30 minutes).

  • Presumed reversible cause of cardiac arrest (e.g., pulmonary embolism, myocardial infarction, severe hypothermia, or drug overdose). That is the primary cause of the cardiac arrest is treatable in time.

  • Age considerations (generally patients <70 years, though this varies by institution).

  • ECPR is reserved for patients who were otherwise healthy. Significant pre-existing comorbidities that would severely limit recovery (e.g. Preexisting severe Neurological Disease, Preexisting disease with high Fatality Rate, must be absent.

  • Witnessed cardiac arrest with immediate initiation of high-quality CPR.

  • Availability of an experienced ECMO team and infrastructure.



The Process of ECPR

  1. Patient Selection and Cannulation:

    • Upon identification of a suitable candidate, a specialized ECMO team initiates femoral veno-arterial (VA) cannulation under ultrasound and fluoroscopic guidance.

    • A large-bore venous cannula is placed in the femoral vein, and an arterial cannula is placed in the femoral artery.

  2. Initiation of ECMO:

    • The ECMO circuit is primed, and extracorporeal blood flow is established.

    • Oxygenated blood is delivered into the arterial circulation, maintaining organ perfusion while further resuscitation efforts continue.

  3. Ongoing Critical Care Management:

    • Treatment of reversible causes, such as percutaneous coronary intervention (PCI) for myocardial infarction or thrombolysis for pulmonary embolism.

    • Management of anticoagulation to prevent clot formation in the ECMO circuit.

    • Hemodynamic and respiratory support to optimize perfusion and oxygenation.

  4. Weaning and Decannulation:

    • If the underlying cause is successfully treated, the patient may be weaned off ECMO support.

    • If neurological recovery is poor or multi-organ failure occurs, withdrawal of care may be considered.

Contraindications of Initiation of ECPR

  • Arrest to CPR Initiation time more than 10 minutes.

  • Prolonged downtime without effective CPR (>60 minutes in most cases).

  • Irreversible causes of cardiac arrest (e.g., massive intracranial hemorrhage, advanced malignancy).

  • Severe pre-existing organ dysfunction (end-stage heart, lung, or liver disease).

  • Lack of ECMO-trained personnel or appropriate hospital infrastructure.

  • Unwitnessed cardiac arrest without signs of life.

Complications of ECPR

  • Bleeding: Due to the necessity of anticoagulation, bleeding complications such as intracranial hemorrhage or access site bleeding are common.

  • Thrombosis and Embolism: Clot formation in the ECMO circuit may lead to stroke or limb ischemia.

  • Infections: Prolonged ECMO use increases the risk of bloodstream infections.

  • Hemodynamic Instability: Rapid changes in circulatory dynamics can cause complications such as left ventricular distension.

  • Neurological Injury: Prolonged hypoxia before ECMO initiation may result in severe anoxic brain injury.

Advantages of ECPR

  • Conventional CPR provides very minimal Cardiac Output an MAP. ECPR can generate higher MAP and better perfusion to major internal organs. Prolonging the time to recovery significantly.

  • Improved survival rates in select patients when compared to conventional CPR.

  • Better neurological outcomes if initiated early in witnessed cardiac arrest.

  • Provides time for definitive treatment of reversible conditions such as acute coronary syndrome, pulmonary embolism, or hypothermia.

  • Can be used as a bridge to definitive therapies such as heart transplantation or long-term mechanical circulatory support.

  • Rapid achievement of Hypothermia can be achieved in ECPR. So TTM (32-26 °C) becomes easier with heat exchanger devices.

Disadvantages of ECPR

  • Resource-intensive and requires highly trained personnel.

  • High cost and limited availability.

  • Not beneficial for all patients; inappropriate patient selection may lead to poor outcomes and prolonged ICU stays.

  • Complications such as infections, bleeding, and neurological deficits are significant concerns.

  • Ethical concerns regarding patient selection and withdrawal of care.



Landmark Trials on ECPR for Adult and Pediatric Patients

Adult Trials:

  1. ARREST Trial (2020): A randomized trial comparing ECPR to conventional ACLS in OHCA patients with refractory ventricular fibrillation showed significantly improved survival with ECPR.

  2. CHEER Trial (2015): Demonstrated improved survival rates with favorable neurological outcomes in OHCA patients managed with ECPR and hypothermia.

  3. SAVE-J Study (2014): A Japanese registry study showed better survival and neurological recovery in patients receiving ECPR versus conventional CPR.

Pediatric Trials:

  1. PEAPETT Trial (2021): Evaluated the use of pediatric ECPR in in-hospital cardiac arrest with promising survival outcomes.

  2. PediRES-Q Registry: A multi-center study showing improved survival and neurological outcomes in children treated with ECPR compared to conventional CPR.

  3. ELSO Pediatric ECPR Database: Data from the Extracorporeal Life Support Organization (ELSO) highlight improved survival in pediatric patients undergoing ECPR compared to traditional resuscitation.

References

  1. Yannopoulos D, Bartos JA, Raveendran G, et al. "Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation." Circulation. 2020;141(23):1859-1870.

  2. Shin TG, Jo IJ, Sim MS, et al. "Extracorporeal cardiopulmonary resuscitation in patients with in-hospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation." Crit Care Med. 2011;39(1):1-7.

  3. Lasa JJ, Rogers RS, Localio R, et al. "Extracorporeal cardiopulmonary resuscitation in pediatric in-hospital cardiac arrest: A propensity score-matched analysis using the American Heart Association’s Get With The Guidelines-Resuscitation Registry." Circulation. 2016;133(2):165-176.

  4. ELSO Registry. "Pediatric ECPR Outcomes." Available at: www.elso.org

ECPR continues to evolve as an important resuscitative tool in refractory cardiac arrest, with ongoing research needed to refine patient selection, improve accessibility, and enhance outcomes.

Good YouTube Videos to learn about ECPR

1. http://youtube.com/watch?v=TAezEMGVgek

2. https://www.youtube.com/watch?v=nM0WC51A9-g

3. https://www.youtube.com/watch?v=JtChylMbRkE

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