Extracorporeal versus Conventional Cardiopulmonary Resuscitation in Refractory Cardiac Arrest: Systematic Review of Survival and Neurological Outcomes

Abstract

Objective: This systematic review compares survival with favorable neurological outcomes following extracorporeal cardiopulmonary resuscitation (ECPR) versus conventional CPR (CCPR) in adults with refractory cardiac arrest.
Methods: We conducted a systematic search of major databases for randomized and observational studies comparing ECPR to CCPR. The primary outcome was survival with a favorable neurological outcome, defined as a Cerebral Performance Category (CPC) of 1 or 2.
Results: Eight studies involving 1,676 patients were included. The pooled analysis demonstrated that ECPR was associated with a 21.2 % rate of favorable neurological outcome compared to 16.7 % with CCPR. The combined relative risk (RR) was 1.27 (95 % CI 1.04–1.56), indicating a statistically significant 27 % relative improvement with ECPR. The absolute risk reduction was 4.5 %, with a number needed to treat of 22. However, significant heterogeneity was observed. The magnitude of benefit was highly dependent on patient and system factors, with the most pronounced advantages seen in patients with an initial shockable rhythm and shorter low-flow times. While one randomized controlled trial (ARREST) reported a large, significant effect (RR 6.43), the larger INCEPTION trial found a non-significant effect (RR 1.24).
Conclusion: ECPR is associated with a significant improvement in survival with favorable neurological outcomes compared to CCPR. This benefit is not universal and appears greatest in selected populations, particularly those with shockable rhythms and rapid access to a highly organized ECPR system. Successful implementation requires robust protocols for rapid deployment and careful patient selection.