ECPR for Out-of-Hospital Cardiac Arrest: Real-World Application of RCT Criteria Yields Comparable Outcomes

Introduction: The role of extracorporeal cardiopulmonary resuscitation (ECPR) in out-of-hospital cardiac arrest (OHCA) remains unclear. Recent RCTs (ARREST, PRAGUE, and INCEPTION) yielded conflicting results on survival and neurological outcomes. This study evaluates the real-world applicability of these trials by comparing their inclusion criteria and outcomes to a cohort treated at Shaare Zedek Medical Center (SZMC).

Methods: Adult OHCA patients with refractory arrest undergoing ECPR at SZMC from 2018–2024 were retrospectively analyzed. Patients were stratified by the inclusion criteria of ARREST, PRAGUE, and INCEPTION trials. Demographic and clinical variables were compared using statistical tests for categorical and continuous variables. Outcomes of our cohort were compared with RCT results, analyzing survival and neurological function.

Results: Among 62 patients (mean age 50.5 ± 15 years, 81% male), 66% had acute coronary syndrome, and 63% had an initial shockable rhythm. Time from EMS call to hospital arrival and ECMO initiation was 42.2 ± 22.4 and 72.5 ± 21.2 minutes, respectively. Hospital discharge survival was 15%, with 9.7% achieving good neurological outcomes (CPC 1–2).

Compared to RCTs, our cohort was younger, had higher rates of diabetes, and included more smokers and patients with chronic heart or lung disease. Despite demographic and procedural differences, no significant outcome differences were observed between our cohort and the RCTs, or between patients meeting versus not meeting RCT inclusion criteria.

Conclusions: Real-world outcomes using RCT inclusion criteria demonstrated similar survival and neurological results, questioning the strict application of such criteria. Further research is needed to refine patient selection for ECPR to optimize resource utilization and patient benefit.