Dr. Dipanjan Chatterjee,
Cardiac arrest remains a critical health challenge, particularly in India, where survival rates are disconcertingly low. However, innovations such as extracorporeal cardiopulmonary resuscitation (ECPR) utilizing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are transforming our approach, significantly enhancing prospects for patient survival and recovery.
Traditional cardiopulmonary resuscitation (CPR) aims to maintain cerebral circulation until spontaneous circulation is restored. Yet, if return of spontaneous circulation (ROSC) is not achieved within 30 minutes, CPR is often discontinued. The stark reality is that optimal neurological outcomes are only likely if ROSC occurs within minutes of cardiac arrest; after 15 minutes, the chance of a favorable recovery diminishes to a mere 2%. Conventional CPR, while life-saving, achieves only about 25% of normal cardiac output, leading to significant tissue hypoxia during prolonged efforts—this period is termed the “low-flow duration.” Compounding this issue is the “no-flow duration,” the interval from cardiac arrest to the initiation of CPR.
ECPR with VA-ECMO addresses these limitations by ensuring sufficient tissue and cerebral perfusion even when traditional CPR fails. The timing of ECPR initiation is crucial. If ROSC is not achieved, the ECMO team should be alerted within the first 10 minutes post-arrest. This proactive approach allows for critical interventions, including diagnostic assessments and treatments for conditions like acute myocardial infarction. Moreover, ECPR facilitates a transition from VA-ECMO to the patient’s circulatory support or consideration for heart transplants or durable mechanical support, should recovery not occur. Selection criteria for ECPR patients include being under 70 years old, having witnessed cardiac arrest, CPR initiated within 5 minutes, an initial rhythm of VT/VF or PEA, a low-flow interval under 60 minutes, and ETCO2 levels exceeding 10 during CPR.
Patients without severe comorbidities, such as advanced renal or hepatic failure, pre-existing neurological deficits, or life-limiting malignancies, stand a better chance of favorable outcomes. However, the implementation of ECPR in India raises ethical considerations and family perceptions, particularly against a backdrop of financial constraints and the long-term care implications. Transparent communication about potential outcomes and costs is vital to facilitate informed decision-making for families. In cases of out-of-hospital cardiac arrest, the logistical and financial challenges of initiating ECPR complicate its application. In-hospital scenarios, while more manageable, still require thorough discussions about financial implications, as outcomes can remain uncertain—even for patients with no prior health issues.
The Extracorporeal Life Support Organization (ELSO) registry indicates a 30% survival rate for adults, 41% for pediatric cases, and 43% for neonates. While predicting individual outcomes remains complex, the rescue score aids in estimating survival probabilities based on variables like low-flow time and existing organ damage. In conclusion, ECPR represents a promising advancement in the management of cardiac arrest, offering hope where traditional methods may falter. As we continue to refine our approaches and enhance access to this lifesaving technology, it is imperative that we also address the systemic challenges that hinder its implementation—ensuring that all patients receive the best possible chance of recovery.
Dr. Dipanjan Chatterjee is Director, ECMO & Transplant Programme(Heart and Lung) & Head, Dept. of Cardio – Pulmonary – Critical Care, Medica Superspecialty Hospital, Kolkata