ECPR
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"extracorporeal cardiopulmonary resuscitation" ECPR
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ECPR extracorporeal CPR indications outcomes 2025 guidelines
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PMID: 37230097
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PMID: 41444922
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Here is a thorough overview of ECPR (Extracorporeal Cardiopulmonary Resuscitation):
What is ECPR?
ECPR is the use of venoarterial ECMO (VA-ECMO) as a form of CPR in patients with cardiac arrest that is refractory to conventional CPR (CCPR). It provides mechanical oxygenation, ventilation, and circulation while the underlying reversible cause is treated. It is also called "ECMO-CPR" or "extracorporeal life support CPR."
ECPR is a bridging therapy - not a definitive treatment. It buys time for percutaneous coronary intervention (PCI), cardiac surgery, ablation, heart transplant, or other definitive interventions. - Tintinalli's Emergency Medicine
Circuit Components
The ECMO circuit used in ECPR includes:
- A blood pump
- A venous reservoir
- An oxygenator (for O2 and CO2 exchange)
- A heat exchanger
- Pressure, SpO2, and temperature monitors
In ECPR, VA-ECMO is the modality used: blood is drawn from the venous circulation (inferior vena cava or right atrium) via a cannula, passed through the oxygenator, warmed, and returned to the patient via a cannula in the femoral artery or aortic arch. This provides both gas exchange AND hemodynamic support. - Tintinalli's Emergency Medicine
When to Use ECPR
ECPR should be considered after 10-15 minutes of unsuccessful conventional resuscitation (per the ELSO consensus), because setup takes time and time-to-ECMO correlates directly with neurological outcome.
Indications (Patient Selection Criteria)
| Favors ECPR | Contraindicates ECPR |
|---|---|
| Good premorbid functional status | Advanced age or frailty |
| Witnessed arrest with immediate bystander CPR | Unwitnessed arrest or no bystander CPR |
| Reversible underlying cause (STEMI, arrhythmia, PE, hypothermia, toxin) | Traumatic cardiac arrest |
| In-hospital cardiac arrest (IHCA) | Advanced malignancy |
| Short no-flow and low-flow intervals | Prolonged arrest >60 min without documented good perfusion |
| Age <75 (institutional criteria vary) | Suspected aortic dissection or severe AR |
| Absence of terminal illness | Pre-existing DNR |
Sabiston Textbook of Surgery; Tintinalli's Emergency Medicine
ECPR Settings: IHCA vs. OHCA
- IHCA: Strong evidence supports ECPR - meta-analysis (Low et al., Lancet Resp Med 2023, 4595 ECPR vs. 4597 CCPR patients) showed significantly reduced in-hospital mortality for IHCA (OR 0.42, 95% CI 0.25-0.70). Higher center volume correlated with better outcomes.
- OHCA: Benefit is more debated. The same meta-analysis showed no significant mortality reduction for OHCA alone (OR 0.76, p=0.12), though a 2025 meta-analysis (Yasmin et al., J Cardiothorac Surg 2025, PMID 41444922) found improved favorable neurological outcomes at discharge (OR 2.61) and 6 months (OR 1.97). Rapid intra-arrest transport for ECPR is now an emerging strategy for highly selected OHCA patients.
Cannulation Strategies
- Peripheral (most common in ECPR): Femoral vein + femoral artery. Rapid bedside cannulation without needing an OR. Risk of limb ischemia - mitigated by a distal perfusion catheter in the superficial femoral artery.
- Central: Used in post-cardiotomy arrest or minimally invasive cardiac surgery settings.
Sabiston Textbook of Surgery
Complications
| Mechanical | Medical |
|---|---|
| Circuit clots | Bleeding/coagulopathy (systemic anticoagulation required) |
| Oxygenator failure | Limb ischemia |
| Pump malfunction | Differential hypoxia ("Harlequin syndrome") |
| Mediastinal bleeding from vessel tears | Infection |
Post-ECPR Management
ECPR must be accompanied by comprehensive post-arrest care:
- Targeted temperature management (32-36°C)
- Hemodynamic goals: MAP 65-100 mmHg, ScvO2 ≥70%
- Early coronary angiography if STEMI is suspected
- Glycemic control: 100-180 mg/dL
- Neurological monitoring for seizures and prognostication
2025 Guidelines (AHA/ERC)
The 2025 AHA and ERC guidelines both updated their ECPR recommendations:
- Centers with ECPR programs should develop and regularly reassess patient selection criteria to maximize survival and ensure equitable access
- Clinicians performing peripheral ECPR cannulation should be experienced in percutaneous technique
- A regionalized approach to ECPR is reasonable to optimize outcomes and resource utilization
- Rapid intra-arrest transport for ECPR may be considered for highly selected OHCA patients
- ECPR is reasonable in pregnant patients in cardiac arrest not responsive to standard resuscitation (reported survival 55-75%)
- For hypothermic arrest, rewarm with VA-ECMO and target ECMO flow within 60 minutes of arrest onset
- For pediatric patients with cardiac diagnoses and IHCA in ECMO-capable centers, ECPR should be considered
Key Evidence Summary
| Study | Finding |
|---|---|
| Low et al., Lancet Resp Med 2023 (PMID 37230097) | ECPR reduces in-hospital mortality overall (OR 0.67); clear benefit for IHCA; improved long-term neurological outcomes (OR 2.04 at ≥90 days) |
| Low et al., Crit Care 2024 (PMID 38383506) | Updated meta-analysis confirming benefit; center volume effect persists |
| Yasmin et al., J Cardiothorac Surg 2025 (PMID 41444922) | ECPR in OHCA - better neurological outcomes at discharge, 3 months, 6 months; improved survival to discharge (OR 1.84) |
| Woszczyk et al., Syst Rev 2025 (PMID 40121472) | Low-flow time, initial rhythm (shockable), and serum lactate are key neurological outcome predictors post-ECPR |
Bottom line: ECPR is a time-sensitive, resource-intensive intervention best suited for witnessed, refractory cardiac arrest with a reversible cause, in high-volume centers with trained teams. The evidence base is strongest for IHCA; OHCA benefit depends heavily on patient selection, time to cannulation, and institutional capability.
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