ECPR can bring people back to life. Can it save more lives than CPR?

A recent University of Florida Health (UF Health) article highlights how extracorporeal cardiopulmonary resuscitation (ECPR) saved a UF Health patient’s life after he experienced cardiac arrest. The patient, the article says, would have died without it. Beyond surviving, he had no resulting neurological or physical damage. He was the first UF Health patient to have met the criteria to receive ECPR for out-of-hospital cardiac arrest.^[] 

Before arriving at the hospital, the patient’s daughter applied conventional cardiopulmonary resuscitation (CCPR), as did emergency medical rescuers who arrived on the scene. The patient received CCPR for more than 45 minutes and was unconscious by the time he arrived at the emergency room.^[]

“Evaluating the patient, Becker and the emergency room team noticed signs of life – specifically that their patient moved his arm during CPR and his pupils were reactive to light,” the article states. At this point, ECPR therapy was provided. Two days later, the patient underwent a two-vessel coronary artery bypass graft surgery.^[] 

“For ECPR, patients typically have two ECMO cannulas placed into the femoral blood vessels. The cannula in the femoral vein drains blood from the body into the machine, where carbon dioxide is removed from the blood and oxygen is added,” Torben Becker, MD, PhD, an Associate Professor in the Department of Emergency Medicine at the UF College of Medicine and Executive Director of Emergency Medicine for the UF Health Critical Care Organization tells MDLinx. “It then pushes that ‘refreshed’ blood back into the femoral artery via the other cannula. From there, it flows through the arteries of the blood, providing perfusion and oxygenation to the tissues.”

As Kenneth Perry, MD, an emergency medicine physician in Charleston, SC, tells MDLinx, “Patients who have had cardiopulmonary arrest can have problems with oxygenation. This can either be the cause of the underlying cardiac arrest, but could also be a downstream effect of a different reason for their severe medical problem.” 

So, when physicians attempt to resuscitate a patient who experienced cardiopulmonary arrest, he says, they have to consider reasons for the arrest, such as acidemia, hypothermia, or hypoxia. “With the ability to connect the patient to a device that is an external means to oxygenate the blood, it removed this cause of cardiopulmonary arrest from the algorithm, allowing for oxygenation that might be impaired by damaged lungs,” Dr. Perry says. 

ECPR may save lives, but it also has its limitations

Like the man whose life was saved at UF Health, patients must meet specific eligibility criteria to receive ECPR. Factors may include witnessed collapse, bystander CPR, initial rhythm, medical conditions, and age, according to a 2023 article published in Intensive Care Medicine Experimental. That said, the article notes, “[T]here is still ambiguity regarding clear inclusion and exclusion criteria. National recommendations differ, and prospectively randomized studies have used different inclusion criteria.”^[]

ECPR is also not a routine procedure. Generally, it’s considered a last-resort option for specific patients—if the technology is even available. Ernie Vesta, MD, Medical Director of Curally, says that while ECPR can save lives, it currently has limited utility “due to the superior and specialized skill and personnel necessary to manage the process,” and that people should not “look for [it] to become the mainstream treatment [for] heart attacks anytime soon, if at all.”^[]

Dr. Becker tells MDLinx that ECPR’s success is deeply rooted in its intense requirement for resources and its reliance on significant interdisciplinary collaboration. “Current evidence suggests that good outcomes with ECPR can primarily be achieved at centers capable of providing this high level of resources and care coordination,” he says. ECPR is also very costly.^[]

ECPR is only available at Centers of Excellence across the country, according to UF Health. For example, UF Health is the only facility in North Central Florida to offer ECPR as part of its prehospital program. The program went live there in March 2023.^[] 

ECPR cases have a 30% survival rate. Many patients may die within days of receiving ECMO, and the “mortality of up to 70% in the ELSO [Extracorporeal Life Support Organization] registry despite ECPR can be particularly burdensome for attending physicians and nursing staff,” as well as patients’ family members, according to an article published in Intensive Care Medicine Experimental.^[]

“Crafting a patient-centered, individualized therapy for the critically ill ECPR cohort presents a formidable challenge, even to experienced teams. Ethical issues are commonly reported in context of ECMO therapy,” the authors continue.^[] “The novel application of technology is the story here, showing an ability to use cutting-edge tech when facing an unlikely scenario because it makes sense to try. Most individuals, in my experience, do not survive if more than 20 minutes of CPR have been completed,” Dr. Vespa says.

Dr. Becker says he hopes for expanded access to ECPR. “However, as we have seen with most medical innovations, it is quite likely that smaller facilities will ultimately also be able to provide ECPR as technology advances and collective medical experience with this technique improves,” he notes.

Despite ECPR’s limitations, the fact that it’s an option for many patients is hopeful, Dr. Perry says: “Cardiopulmonary arrest and the subsequent resuscitation that occurs are very serious events that have outcomes [that are] not as positive as Hollywood would like us to think. Anything that can increase or improve outcomes is obviously going to be a great adjunct to resuscitating these patients.”.