Long-term Neurological Outcomes After Extracorporeal Cardiopulmonary Resuscitation for Refractory Cardiac Arrest: A 14-Year Single-Center Cohort Study

Background.Extracorporeal Cardiopulmonary Resuscitation (ECPR) via Veno-Arterial Extracorporeal Membrane Oxygenation (ECMO) is a viable treatment for refractory cardiac arrest (r-CA).Data on longterm outcomes and predictors of favourable neurological prognosis remain limited, and definitive patientselection recommendations are lacking.Methods.We conducted a retrospective observational study of adult patients treated with ECPR for inhospital (IHCA) and out-of-hospital (OHCA) r-CA at an Italian ECMO centre between 2011 and 2024.The primary outcome was long-term neurological performance, measured by the Cerebral Performance Category (CPC) scale six months after hospital discharge.Multivariable and latent class analyses assessed independent predictors and explored distinct pre-ECPR phenotypes.Results.Among 295 consecutive patients (117 IHCA; 178 OHCA), 17.3% achieved CPC 1-2 at six months (28.2%IHCA vs 10.1% OHCA; p<0.0001), and 4.4% survived with severe long-term neurological sequelae (CPC 3-4).Independent predictors of CPC 1-2 were younger age (OR 0.95 per year, 95% CI 0.92-0.98),an initial shockable rhythm (aOR 2.7; 95% CI 1.11-7.04),and shorter low-flow duration (OR 0.95 per minute increase, 95% CI 0.93-0.97).Stepwise selection based on these criteria progressively increased the proportion of favourable survivors but excluded a small proportion who might have recovered.Conclusions.These results emphasise the importance of establishing pre-treatment selection criteria to optimise ECPR use and enhance long-term neurological outcomes.Age, initial rhythm, and low-flow time are key determinants, and exploratory phenotype-based analyses suggest multidimensional patient characterisation may complement traditional selection criteria..