Beyond the protocol: real-world application of eCPR and associated outcomes - insights from the german cardiac arrest registry (G-CAR)

Background Extracorporeal cardiopulmonary resuscitation (eCPR) is a treatment option for selected patients with refractory out-of-hospital cardiac arrest (OHCA). Data from randomized controlled trials (RCTs) highlight the importance of adequate patient selection. Expert consensus statements recommend six criteria for eCPR suitability: age ≤75 years, witnessed OHCA, bystander cardiopulmonary resuscitation (CPR), no-flow time ≤5 minutes (min), low-flow time ≤60 min, and an initial shockable rhythm. Although widely accepted, these items are not supported by robust data and adherence varies greatly. We present an analysis from the German Cardiac Arrest Registry (G-CAR) describing the current state of eCPR across participating centers. Results Of 1,644 patients in G-CAR, 576 patients (34.6%) were admitted with ongoing CPR. Of these, 162 (28.0%) were treated with eCPR. Only 18 patients (11.0%) met all six eCPR criteria, with the majority displaying five (60.4%) or four (42.3%) characteristics. Overall, the rate of favorable neurological survival at 30 days was higher in patients treated with eCPR than in those treated conventionally (8.6% vs. 5.6%, p<0.001). When stratified according to the number of criteria, the probability of survival was significantly higher in patients meeting all six (20.0%) or five (11.9%) criteria. The same differences were observed in patients without eCPR. Conclusions Adherence to proposed eCPR selection criteria was rather low in this real-world cohort, potentially contributing to lower survival rates compared with results from RCTs. However, when all criteria were fulfilled, survival rates were significantly higher underscoring the need for careful patient selection for eCPR.