Beating the clock: time-targeted and individualized extracorporeal cardiopulmonary resuscitation

PURPOSE OF REVIEW: Extracorporeal cardiopulmonary resuscitation (ECPR) improves survival in selected patients with refractory cardiac arrest, but the benefit is steeply time-dependent. We examine the converging rationale for delivering resuscitation that is simultaneously time-targeted and individualized, and its translation into systems of care. RECENT FINDINGS: Pooled randomized data confirms a clinically meaningful survival advantage for ECPR in refractory shockable out-of-hospital cardiac arrest, while observational cohorts show a steep fall in neurologically favorable survival as low-flow time lengthens beyond 30 min. Recent analyses demonstrate that faster cannulation is independently associated with survival, and prehospital and hybrid delivery models have demonstrated an increase in access to cannulation within the therapeutic window. In parallel, individualized selection integrating rhythm, cardiac arrest characteristics, and physiologic markers refine candidacy beyond rhythm alone. SUMMARY: ECPR success depends on systems engineered to achieve rapid cannulation in appropriately selected patients. Prospectively testing advanced ECPR systems of care within a tightly constrained therapeutic window represents the next step in defining how time-targeted, individualized resuscitation should be delivered.