Extracorporeal Cardiopulmonary Resuscitation (ECPR) in Adults: Improving the Odds? Christopher Bishop Clinical Perfusionist Barts Heart Centre

Cardiac Arrest Outcomes Out-of-hospital arrest (OHCA) – 8.6% survival to discharge In-hospital arrest (IHCA) – 14.6%

Cardiac Arrest – The Chain of Survival

CPR Haemodynamics and Survival Optimal CPR generates CI 0.6 L/min/m2 (25-33% of normal) ↑Coronary/cerebral perfusion pressure vital for ROSC during CPR Interruptions to compressions ↓survival Could extracorporeal resuscitation better target haemodynamics and oxygenation?.........

Advanced Life Support – Guidelines 2015

CoSTR 2015 – Extracorporeal CPR (ECPR) Recommendation: “We suggest ECPR is a reasonable rescue therapy for selected patients with cardiac arrest when initial conventional CPR is failing in settings where this can be implemented”

What is ECPR? Emergency initiation of ECLS during refractory cardiac arrest Cannulation and high-quality CPR undertaken simultaneously Variety of settings – ED, ITU, Catheterisation Laboratory, Pre-hospital Augments end-organ perfusion and haemodynamics during arrest Buys time to identify/treat underlying cause and achieve ROSC (e.g. PE, MI, drug overdose

ECPR Set-Up

ECPR “without walls”….

ECPR following mechanical chest compressions From: Menegazzi et al. Resuscitation (2012) 83(1): 130-133

Haemodynamic and metabolic parameters following ECPR ↑pH ↑MAP ↑Tissue O2 saturations (NIRS) ↑PO2 ↓PCO2 ↓Plasma K+ From: Mlcek et al. (2012) Physiol. Res. 61 (Suppl. 2): S57-S65, 2012

ECPR Outcomes - ELSO

Ouweneel et al. 2016

Patient Selection for ECPR Age <60 years Initial rhythm VF/VT Chest compressions within 10 mins arrest Refractory arrest >30 mins No ROSC despite standard ALS No major comorbidities Likely reversible cause (hypothermia/intoxication/ACS)

CHEER Results 54 % Survival!

55% Survival!

ECPR in the Future? Pre-hospital ECMO Heart Attack Centre Cardiac Cath Lab ECMO ICU

Summary ECPR has strong physiological and evidence base to support use and ongoing development Larger studies required: - To improve case selection - Allow comparison between services -Compare conventional CPR and ECPR outcomes

Thank You!