Extracorporeal cardiopulmonary resuscitation strategies for refractory out-of-hospital cardiac arrest

Abstract Background Refractory out-of-hospital cardiac arrest (OHCA) is almost invariably fatal. Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a feasible rescue treatment and may improve outcomes in highly selected patients. On-scene and hospital-based ECPR each have distinct strengths and limitations, but a real-world comparison of their association with survival is lacking. Methods We analysed a multicentric prospective registry of 52,505 OHCAs in the Greater Paris area (France), from May 2011 to August 2024. We quantified the association between an on-scene ECPR strategy and survival to hospital discharge with favourable neurological outcome (defined as a Cerebral Performance Category 1 or 2), compared to a hospital-based ECPR strategy, adjusting for established prognostic factors, with multivariable and propensity score methods. Results A total of 1,031 patients treated with ECPR were included (16% were female, median age 50 years). Of them, 256 patients received on-scene ECPR, with favourable neurological outcome in 13%, compared to 6% in 775 patients with hospital-based ECPR ( P < 0.01). The time from CPR to ECPR initiation was shorter with the on-scene strategy (70 min [60–84] vs. 93 min [75–113], P < 0.01). In multivariable analysis, the on-scene ECPR strategy was independently associated with favourable neurological outcome (OR, 2.3; 95% CI, 1.4–3.9; P < 0.01). These findings were consistent in propensity score–matched analyses (OR, 2.1; 95% CI, 1.1–4.1; P = 0.03). For IPTW, OR 2.3, 95%CI 1.4–3.9, P<0.01). At one year of follow-up, there was a significant association between the on-scene ECPR strategy and overall survival, (log-rank test, P < 0.01). Conclusions In this large, population-based registry of refractory OHCA, the on-scene ECPR strategy was associated with a significantly shorter time to ECPR initiation and favourable neurological outcome at hospital discharge when compared with the hospital-based ECPR strategy. These findings highlight the potential interest of an on-scene ECPR strategy in selected patients, but further investigations are warranted. Large, randomized controlled trials and studies conducted in diverse healthcare systems are needed to clarify its role more precisely, particularly regarding long-term neurological recovery, cost-effectiveness, and broader system-level impact.