Early ECMO-Facilitated Resuscitation vs ACLS for OHCA and Refractory Ventricular Fibrillation

In patients with out-of-hospital cardiac arrest (OHCA) and refractory ventricular fibrillation, early extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation was found to improve survival to hospital discharge compared with standard treatment using advanced cardiac life support (ACLS), according to a study published in the Lancet.

In this phase 2, open-label Advanced Reperfusion Strategies for Refractory Cardiac Arrest trial (ClinicalTrials.gov Identifier: NCT03880565), 30 adults (average age, 59 years) with OHCA and refractory ventricular fibrillation with no return of spontaneous circulation after 3 shocks were enrolled. All patients had automated cardiopulmonary resuscitation with a Lund University Cardiac Arrest System and an estimated transfer time <30 minutes.

Patients were randomly assigned to receive early ECMO-facilitated resuscitation or standard ACLS at time of hospital arrival (n=15 in each group). Survival to hospital discharge was the study’s primary outcome. Secondary outcomes were safety, survival, and functional assessment at hospital discharge, and 3 and 6 months following discharge.

A greater percentage of patients in the early ECMO vs ACLS group survived to hospital discharge (43% vs 7%, respectively; risk difference, 36.2%; 95% CI, 3.7–59.2; posterior probability of ECMO superiority, 0.9861). The cumulative survival was also better with early ECMO vs standard ACLS treatment (hazard ratio, 0.16; 95% CI, 0.06–0.41; P <.0001). All patients who survived had good functional scores at the 6-month follow up.

The very critically ill population in the early ECMO group frequently experienced serious multiorgan injury. There were no unanticipated serious adverse events related to ECMO. A total of 13 patients died in the standard ACLS group because of unsuccessful resuscitation and inability to achieve return of spontaneous circulation. The study was terminated, per recommendation from the trial’s Data Safety Monitoring Board, at the first preplanned interim analysis.

A limitation of this study was the sole inclusion of patients treated at an emergency healthcare center with highly experienced interventional critical care cardiology providers, which may limit generalizability.

 “The ARREST trial confirmed that standard ACLS resuscitation alone for this patient population had a dismal outcome,” concluded the study authors.

Reference

Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020;396(10265):1807-1816. doi:10.1016/S0140-6736(20)32338-2