Mechanical circulatory support for refractory out-of-hospital cardiac arrest: a nationwide multicentre study

Abstract Background Extracorporeal cardiopulmonary resuscitation (ECPR) has shown potential as a salvage therapy for patients with refractory out-of-hospital cardiac arrest (OHCA). The objective of this study was to to describe the gradual implementation, survival and adherence to the national consensus with respect to use of ECPR for OHCA in Denmark, and to identify factors associated with outcome. Methods This retrospective, observational cohort study included patients receiving ECPR for OHCA at all tertiary cardiac arrest centers (n = 4) in Denmark between July 2011 and December 2020. Logistic regression and Kaplan-Meier survival analysis were used to determine association with outcome. Outcome was presented as survival to hospital discharge with good neurological outcome, 30-day survival and predictors of 30-day survival. Results A total of 259 patients were included in the study. Thirty-day survival was 26% and a good neurological outcome (Glasgow-Pittsburgh Cerebral Performance Categories (CPC) (CPC 1–2)) was observed in 94% of patients at discharge. Strict adherence to the national consensus showed a 30-day survival rate of 30% compared with 22% in patients violating one or more criteria. Adding criteria to the national consensus such as signs of life during cardiopulmonary resuscitation (CPR), pre-hospital low-flow < 100 minutes, pH > 6.8 and lactate < 15 mmol/L increased the survival rate to 48%, but would exclude 58% of the survivors from the current cohort. Logistic regression identified asystole (RR 1.36, 95% CI 1.18–1.57), pulseless electrical activity (RR 1.20, 95% CI 1.03–1.41), initial pH < 6.8 (RR 1.28, 95% CI 1.12–1.46) and lactate levels > 15 mmol/L (RR 1.16, 95% CI 1.16–1.53) as factors associated with increased risk of 30-day mortality. Patients presenting signs of life during CPR had a threefold higher survival rate compared to patients without signs of life (45% versus 13%, p < 0.001). Conclusions A high survival rate with a good neurological outcome was observed in this Danish population of patients treated with ECPR for OHCA. Stringent patient selection for ECPR may produce higher survival rates but potentially withholds life-saving treatment in a significant proportion of survivors, why optimization of the selection criteria is still necessary.