Abstract Or115: Execution of Transesophageal Echocardiography in Cardiopulmonary Resuscitation for Patients with Out-of-hospital Cardiac Arrest (EXECT-CPR): A Clustered Randomized Clinical Trial

Background: Current cardiopulmonary resuscitation (CPR) guidelines recommend chest compressions at "the center of the chest." However, studies have shown that over half of patients with out-of-hospital cardiac arrest (OHCA) experience aortic valve (AV) compression following this recommendation, which may worsen outcomes. We hypothesized that using transesophageal echocardiography (TEE) to guide chest compressions in adult OHCA patients, avoiding AV compression and targeting the left ventricle (LV), would improve outcomes compared to the conventional site. Methods: The EXECT-CPR trial was a single-center cluster randomized clinical trial enrolling adults (≥20 years old) with non-traumatic OHCA presenting to the emergency department (ED). Exclusion criteria included return of spontaneous circulation (ROSC) before ED arrival, extracorporeal CPR, pre-existing contraindications for TEE, do-not-resuscitate orders, or obvious signs of death. Patients were assigned to the TEE-guided or conventional group using biweekly cluster randomization. Both groups received standard advanced life support, except the intervention group's compression site, which was initially conventional then rapidly adjusted by TEE. The primary outcome was sustained ROSC (≥20 mins). Secondary outcomes included survival to ICU and discharge with favorable neurological outcomes. The sample size was estimated at 66/group. Analyses were performed on intention-to-treat (ITT) and per-protocol (PP) basis. Results: From June 26 to November 15, 2023, a total of 262 OHCA patients were sent to the ED, and 132 were enrolled in the final analysis (mean age 65 years, 66% male), with 66 in each group. In the TEE-guided group, TEE was successfully imaged in 53 patients (5.3 mins after arrival at the ED). Due to clinical situations, only 46 patients completed the assigned TEE-guided interventions. Of these, 35 patients, who were initially not compressed at the LV, had their compression sites successfully adjusted (9.2 mins after arrival at ED). In ITT analysis, the primary outcome was 29/66(43.9%) in the TEE-guided group and 26/66(39.4%) in the conventional group (odds ratio[OR] 1.21, P=0.60), while in PP analysis it was 20/46(43.5%) and 26/66(39.4%) (OR 1.18, P=0.67; adjusted OR 1.63, P=0.28). Secondary outcomes showed no significant differences. Conclusion: Among adults with non-traumatic OHCA, TEE-guided CPR with an adjusted compression site in the ED did not result in different outcomes compared to conventional CPR.