Thread by @tscquizzato

🔸ECPR improves survival with good neuro outcome🔸

We just published the first meta-analysis of 4 RCTs

➡️ More OHCA patients had good neuro outcome when randomized to #ECPR (27% vs 18%, p=0.02)

🧵 Learn more in the thread /11

🔗 onlinelibrary.wiley.com/doi/full/10.11…

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2/

In refractory OHCA, VA-#ECMO during ongoing CPR, known as #ECPR, can restore and maintain organ perfusion limiting brain injury

Growing evidence suggest that this approach can improve survival and neuro outcome

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3/

After decades of evidence from non-RCTs, 3 single-center RCTs investigated #ECPR vs conventional CPR and 2 suggested a potential benefit

In 2023, the first multi-center RCT (INCEPTION) was published and showed no major differences in outcomes

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4/

INCEPTION trial results contrasted with previous studies and expert opinions generating intense debate around #ECPR

Therefore, to ascertain the effect of ECPR vs conventional CPR we conducted a meta-analysis focusing on RCTs only (4 studies, 433 pts)

https://twitter.com/tscquizzato/status/1618514989010284544

5/

In our meta-analysis of RCTs, survival with favorable neuro outcome at the longest follow-up was higher with #ECPR vs conventional CPR (27% vs 18% p=0.02)

The highest benefit was observed in patients with an initial shockable rhythm (34% vs 23% p=0.01)

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6/

In terms of number needed to treat (#NNT), to achieve 1 additional survivor with good neuro outcome we should treat with #ECPR

- 9 (95% CI, 5-66) pts with all-rhythm refractory OHCA
- 7 (95% CI, 4-31) with an initial VF

and favorable characteristics.

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7/

While we demonstrated that #ECPR improved survival with good neuro outcome, no differences in overall survival at hospital discharge or 30 days and at 3 or 6 months were found when pooling these 4 RCTs

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8/

All RCTs, except EROCA pilot trial, reported a consistent direction of effect in favour of #ECPR, with ARREST and Prague OHCA study reporting a statistically significant difference up to 180 days and at 30 days only, respectively

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https://twitter.com/tscquizzato/status/1496241433354936324

9/

#ECPR is highly debated due to the important resources needed despite it’s a lifesaving intervention now supported by high-quality RCTs

However, it should be noted that beneficial effects in this meta-analysis is driven by 2 RCTs in single, high-performing centers.

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10/

Implementing #ECPR in different settings/systems might fail to reproduce beneficial effects observed in this meta-analysis of single-center RCTs

ECPR is complex and requires a well-organized system, experience and a high-volume ECMO-capable cardiac arrest centers

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11/

Future research should aim to identify the most effective strategy to provide #ECPR based on system-level characteristics, address logistical barriers of extracorporeal CPR, and improve patient selection

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