Extracorporeal cardiopulmonary resuscitation may improve survival and neurologic outcomes in selected patients with cardiac arrest, but evidence remains limited and its broader use raises significant ethical and resource challenges, according to a review article.
In the review, researchers discussed randomized trials, observational studies, meta-analyses, and registry data on extracorporeal cardiopulmonary resuscitation (eCPR), in which extracorporeal membrane oxygenation is used during resuscitation for refractory cardiac arrest. The paper emphasized that although eCPR shows promise, the overall evidence base is heterogeneous and largely derived from specialized centers, limiting generalizability.
Across cited studies, eCPR was associated with improved survival to hospital discharge and at 30 and 180 days compared with conventional cardiopulmonary resuscitation, although findings varied across study designs and patient populations. A meta-analysis of 14,048 patients reported improved short-term neurologic outcomes and higher 30-day survival with eCPR. Another analysis found survival with favorable neurologic status in 14% of patients treated with eCPR vs 7% with conventional cardiopulmonary resuscitation.
The researchers emphasized several limitations, including variability in patient selection, lack of standardized eligibility criteria, and confounding in observational data. Most studies prioritized survival without fully assessing long-term neurologic function or quality of life.
Outcomes appeared highly dependent on timing. Earlier initiation of eCPR was associated with improved neurologic recovery. In one study cited in the review, neurologically favorable survival was 100% among patients who received eCPR within 29 minutes vs 24% with conventional cardiopulmonary resuscitation, although this finding was based on a highly selected cohort.
Complications were common and contributed to morbidity and mortality. Reported adverse events included bleeding in 8% to 70% of patients, infections in 8% to 22%, and limb ischemia in 3% to 15%. Neurologic injury remained a major determinant of outcomes, with approximately 10% of patients meeting criteria for death by neurologic criteria.
The review also highlighted substantial system-level and ethical challenges. Because eCPR requires specialized teams and intensive care unit resources, access is limited and may exacerbate disparities in care, particularly between urban and rural settings and across health care systems with differing resources. The researchers noted that eCPR may be available only in well-resourced centers, raising concerns about inequitable access and the potential for a two-tiered system of care.
The review placed particular emphasis on organ donation following eCPR, describing it as both a potential benefit and a source of ethical tension. A cited systematic review of 13 studies including 130 donors reported 322 transplanted organs with favorable graft and recipient outcomes. However, the researchers cautioned that decisions to initiate or continue eCPR should prioritize patient benefit and not be influenced by the potential for organ preservation.
The researchers also highlighted the impact of eCPR on patients’ families. Prolonged intensive care unit stays and uncertain neurologic outcomes may extend the period of emotional distress, with some family members reporting anxiety, depression, or post-traumatic stress. While eCPR may allow time for families to gather and process events, it may also prolong uncertainty and create false hope.
Evidence on quality of life remains limited. Studies cited in the review found no statistically significant differences between eCPR and conventional cardiopulmonary resuscitation, although the analysis included a very small number of eCPR patients and was likely underpowered. The researchers also noted that eCPR may provide additional time for diagnosis and decision-making but may prolong treatment in patients with uncertain prognosis.
“Responsible, patient-centered application, alongside ongoing ethical reflection and rigorous scientific evaluation will be essential for its appropriate integration into future resuscitation strategies,” Rajsic and colleagues wrote.
The researchers reported no conflicts of interest.
