What is Extracorporeal Cardiopulmonary Resuscitation (ECPR)?

From the Guidelines

ECPR, or Extracorporeal Cardiopulmonary Resuscitation, is an advanced life support technique that uses extracorporeal membrane oxygenation (ECMO) during cardiac arrest when conventional CPR is ineffective, and its use may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers 1.

Definition and Purpose of ECPR

ECPR involves quickly connecting a patient to a heart-lung machine that circulates and oxygenates blood outside the body, allowing the heart and lungs to rest while maintaining blood flow to vital organs.

• The procedure requires a specialized team including cardiac surgeons, intensivists, perfusionists, and nurses, and must be initiated rapidly, ideally within 30-60 minutes of arrest.
• ECPR works by providing temporary cardiopulmonary support, giving medical teams time to identify and treat the underlying cause of cardiac arrest while preventing irreversible organ damage from prolonged lack of circulation.

Indications and Recommendations for ECPR

ECPR is typically reserved for specific situations such as:

• Witnessed cardiac arrests with immediate CPR
• Young patients with minimal comorbidities
• Potentially reversible causes of cardiac arrest The American Heart Association recommends that ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers (Class 2b; Level of Evidence C-LD) 1.

Evidence and Outcomes

Though resource-intensive and available primarily at specialized centers, ECPR has shown promising survival rates in carefully selected patients who would likely not survive with conventional resuscitation methods.

• A study published in Critical Care Medicine in 2024 discussed the importance of post-cardiac arrest care in adult patients after ECPR, highlighting the need for standardized management approaches and heterogenous definitions in clinical research 1.
• The 2019 American Heart Association focused update on advanced cardiovascular life support also discussed the use of ECPR during cardiac arrest, noting that there is insufficient evidence to recommend the routine use of ECPR for patients with cardiac arrest 1.

From the Research

Definition of eCPR

• Extracorporeal cardiopulmonary resuscitation (eCPR) is the implementation of extracorporeal membrane oxygenation (ECMO) in selected patients with cardiac arrest, as stated in the latest international guidelines 2.
• eCPR is a salvage procedure in which ECMO is initiated emergently on patients who have had cardiac arrest and on whom conventional cardiopulmonary resuscitation (CCPR) has failed 3.
• The term eCPR refers to cannulating a patient to an ECMO circuit to provide perfusion after cardiac arrest refractory to standard cardiopulmonary resuscitation 4.

Indications and Considerations for eCPR

• eCPR should be considered when the cardiac arrest is witnessed, the patient receives high-quality cardiopulmonary resuscitation, the patient is at or in close proximity to an ECMO center, and there is a reversible cause for the cardiac arrest 4.
• Indications for eCPR include young age, witnessed arrest with bystander cardiopulmonary resuscitation, an initial shockable rhythm, correctable causes such as a cardiac etiology, and no return of spontaneous circulation within 10-20 minutes of CCPR 5.
• Favorable outcomes are associated with a shorter low-flow time, an initial shockable rhythm, lower serum lactate levels, higher blood pH, and a lower Sequential Organ Failure Assessment score 5.

Implementation and Risks of eCPR

• eCPR is a complex intervention that requires a highly trained team, specialized equipment, and multidisciplinary support within a healthcare system 2, 5.
• eCPR has the risk of several life-threatening complications, and physicians should carefully select patients for eCPR who can gain the most benefit 5.
• Structured communication and clearly defined processes are essential, especially at the interface between prehospital rescue teams and the eCPR team, to achieve the highest possible benefit for cardiac arrest patients using eCPR 2.