Pros and Cons of Extracorporeal Cardiopulmonary Resuscitation (ECPR)

Given the persistently poor outcomes for cardiac arrest victims both inside and outside the hospital setting, responders always need to stay current on innovations and technology that can improve care. Extracorporeal cardiopulmonary resuscitation (ECPR) — resuscitation with the support of a venoarterial extracorporeal membrane oxygenation (VA-ECMO) device — is one such tool that responders are turning to with more frequency. Although only a small percentage of cardiac arrest victims receive ECPR, its use is steadily increasing for both in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA).¹

It may sound ideal to have a device externally oxygenate the patient’s blood and provide circulatory support during resuscitation — and in some cases it is. Under the right conditions, ECMO can enhance standard CPR and support better patient outcomes. But it’s also an invasive procedure that comes with its own risks and considerations before use, and it may not be appropriate for every patient.

In this article, we will cover the basics first: What is ECPR, and where exactly does it fit into cardiac arrest care? Then we’ll weigh its pros and cons and identify some key takeaways for future use.

ECPR basics: What is it and when is it used?

What is ECPR?

During ECPR, providers use a portable ECMO machine to oxygenate the blood and support organ function during resuscitation efforts. The ECMO circuit withdraws oxygen-poor blood from a venous cannula, circulates the blood through an oxygen-rich membrane, and then returns the oxygenated blood through an arterial cannula. Whereas conventional CPR can produce only 25% to 30% of cardiac output, ECMO provides sufficient supply to the organs in a life-threatening emergency like cardiac arrest.²

When is ECPR used in cardiac arrest?

Responders may consider ECPR as an option when conventional CPR is ineffective — also called refractory cardiac arrest. Although there’s no single definition or magic number, responders typically deem cardiac arrest refractory after 10-30 minutes of CPR or three defibrillations without return of spontaneous circulation.¹

Currently, the American Heart Association (AHA) endorses this case-specific use of ECPR in select patients with refractory cardiac arrest, citing insufficient evidence to support more routine use across cardiac arrest victims.³

Pros of ECPR

Bridge to treatment

ECPR can serve as a lifesaving bridge to treatment in cardiac arrest patients. By using ECMO to stabilize the patient and maintain circulation to the organs, responders can work to address causes of the patient’s arrest that may be reversible.

Improved outcomes

As the AHA’s stance demonstrates, the use of ECMO in cardiac arrest could certainly benefit from more research — and particularly from more randomized controlled trials. But at the same time, there’s no denying that the research that has been done is promising. For IHCA patients who receive ECPR, studies have shown a 37.9% survival rate.⁴ What’s more, 84.4% of those survivors demonstrated a positive neurologic outcome.⁴ Given the overall low survival rate for IHCA and the neurologic challenges survivors face post-arrest, these outcomes are hard to ignore.

Although there are more challenges to implementing ECMO in a less controlled environment like OHCA, studies suggest there may be benefits in the out-of-hospital setting as well.^1-2 The survival rate for OHCA patients who receive ECMO spans 6.0% to 56.0%, a wide range that may be due to variation in selection criteria across studies.^1,5,6

Cons of ECPR

Unanswered questions

ECMO is still in its infancy as a treatment for cardiac arrest, and research that would help guide its use is ongoing. For example, researchers are still investigating specific clinical characteristics (e.g., lactate levels, serum plasma, etc.) that might make certain patients ideal candidates over others. Understanding exactly who ECPR is for — and who it’s not — is a key question that researchers are still looking to answer more fully.

Resource-intensive

ECPR is a complex, highly specialized treatment that requires more resources and staffing support than standard CPR efforts alone. Providers need to be trained, skilled, and ready to cannulate a patient in a high-risk environment, which can add another layer of stress during an already pressure-filled emergency event.

Risk of adverse effects

ECMO can be lifesaving for some patients, but it’s also an invasive procedure that comes with its own set of risks. Infection, vascular damage, bleeding/hemorrhage, and limb ischemia are potential complications for patients who receive ECPR.²

Key takeaways

What does all this mean for ECPR use — now and in the future? There are a few key takeaways to keep in mind:

1. Although we still have a lot to learn, the bottom line is that ECPR can offer important benefits compared to conventional CPR. This is particularly true for IHCA patients. With studies demonstrating improved survival to discharge and neurologic outcomes, ECPR clearly shows promise — and is worth continued research, discussion, and consideration as a treatment modality for cardiac arrest.

2. Continued research is essential to better inform use of ECPR in cardiac arrest. Key questions to answer include:

• What patient characteristics should be considered for inclusion/exclusion? Which patients benefit most from ECPR? Establishing clear indications and contraindications will help maximize the benefit of ECPR while reducing complications and adverse events.
• How can responders better support OHCA victims who receive ECPR? It’s important to consider OHCA-specific solutions as the out-of-hospital setting is a less controlled environment, with more barriers to availability and rapid implementation.

3. Successful ECMO cannulation during a high-risk emergency event requires training, staffing, resources, and support. Hospitals with an ECPR program should be prepared to properly train and equip responders to ensure that the intervention is streamlined, well integrated into the overall code response, and as seamless as possible.