Vall d'Hebron has shown that extracorporeal membrane oxygenation (ECMO) improves survival in patients with refractory cardiac arrest. This study, published in the journal of the Spanish Society of Intensive Care, Critical Care and Coronary Care Medicine (SEMICYUC), shows the good results of the implementation of the Extracorporeal Cardiopulmonary Resuscitation (ECPR) programme at Vall d'Hebron University Hospital, and places it as a benchmark in the use of this technology, on a par with international reference centres.

ECMO is an advanced life support technique that temporarily replaces the functions of the heart and lungs when they are unable to function on their own. In a cardiac arrest scenario, where traditional methods such as chest compressions and defibrillation fail to restore the heartbeat, ECMO is used to oxygenate blood out of the body and bring it back to the patient. This allows circulation to be restored in order to treat the cardiac arrest and give the affected organs time to recover: this is known as extracorporeal cardiopulmonary resuscitation (ECPR) and offers survival options to patients who would otherwise have none.

The Vall d'Hebron team has analysed the results of the implementation of the ECPR programme between January 2019 and April 2023. During this period, it was applied to 54 adult patients treated in the hospital. Of these, 29 suffered cardiac arrest outside the hospital and 25 within the hospital setting. The most frequent cause was acute myocardial infarction in more than half of the cases. Patients were followed up for 180 days.

The study shows that 16 patients (29.6%) survived to 180 years after the intervention, 15 of them with a complete neurological recovery without sequelae. "Our results are similar to those obtained by other leading international centres in the technique. We demonstrate, therefore, that the ECPR programme of Vall d'Hebron allows improving survival and offering therapeutic options to patients in whom it is not possible to restore cardiac activity with conventional resuscitation techniques and who had no other alternative to survive", says Dr. Eduard Argudo, adjunct of the Intensive Care Medicine Department, ECPR referent at Vall d'Hebron University Hospital and principal investigator of the Shock, Organ Dysfunction and Resuscitation group of VHIR.

"The Cardiology Department also has a fundamental role in the management of these patients, as the most common cause of cardiopulmonary arrest is cardiovascular. In this sense, it is necessary a comprehensive work that involves the collaboration of the different sections of the service (haemodynamics, arrhythmias, imaging, cardiovascular critical care) for a correct diagnosis and treatment", says Dr. María Vidal Burdeus, from the Cardiology Service of the Vall d'Hebron University Hospital and researcher of the Cardiovascular Diseases group at VHIR.

SEM coordination is critical to enable ECPR in out-of-hospital cases

Out-of-hospital, the Catalan Medical Emergency System (SEM) is a key player in the identification of these patients with the initiation of cardiopulmonary resuscitation manoeuvres in the first few minutes and transfer to high-volume centres. In this case, the role of the Central Health Coordination Centre and the SEM care teams is fundamental. "Since the first ECMO patient transfer in August 2016, we have been aware of the need to deepen ECMO therapy as part of the CPR processes in our environment with centres with a developed programme and with the capacity to receive patients who could benefit from this technique", explains Dr Jorge Morales, medical director of the SEM and one of the authors of the study.

Therefore, initially, patients were referred when they were considered to meet CPR criteria, until a positive synergy was established between the Vall d'Hebron University Hospital and the SEM, suggesting the embryo of the ECMO CPR programme in Catalonia, which began in October 2023.

SEM is at the heart of the coordination to make an out-of-hospital ECRP programme feasible. "The results of this study are promising for patients who until recently had no life-saving alternative", adds Dr Morales.

Speed of ECMO initiation and cardiac electrical rhythm influence survival

To understand the factors that affect the survival of patients receiving this support, the study revealed that patients who suffered the arrest in hospital had a slightly higher survival rate (36%) compared to patients who suffered the arrest outside the hospital (24.1%). These results highlight the importance of rapid initiation of ECMO to restore blood flow and increase the chances of survival. For this reason, it is essential to have, as Vall d'Hebron Hospital has, an expert ECMO team with extensive experience and training, as well as coordination between hospitals and the Emergency Medical System to continue improving results also in out-of-hospital cases.

The study also looked at outcomes based on heart rhythm at the time of arrest. Patients with a cardiac rhythm requiring defibrillation (ventricular fibrillation or ventricular tachycardia) showed better survival outcomes. Of these patients, 33.3% survived with a good neurological outcome at 180 days. In contrast, patients with a non-fibrillable cardiac rhythm had lower survival rates (21.2%).

A new opportunity for organ donation

In addition to the direct benefits on patient survival and quality of life, the ECPR programme at Vall d'Hebron has had a positive impact on organ donation. The study showed that of the patients who received ECPR and did not survive, 30.3% were organ donors. "This underlines the added value of ECPR, which not only saves lives in critical situations, but also contributes significantly to organ donation, offering a second chance to others", adds Dr Argudo.

Vall d'Hebron, a reference in ECMO and ECPR

Vall d'Hebron is a world leader in the use of ECMO, with more than 530 adult patients treated since the programme was launched. The quality of care, adherence to the recommendations of international organisations such as ELSO, participation in international research networks and commitment to the training of its professionals stand out.

The fact that Vall d'Hebron is a reference in the care of cardiac arrest, ECMO and accidental hypothermia provided the ideal environment for the implementation of the ECPR programme at the hospital, with the first case in 2017. During 2018 and 2019, a protocol on indications, contraindications, procedure details, team organisation and patient management before, during and after ECMO was prepared. Subsequently, multiple informative sessions and multidisciplinary training courses with simulation have been held. So far, more than 120 patients with refractory cardiac arrest have received ECPR in Vall d’Hebron.

The key to achieving the good results shown in the study is the high level of specialisation, experience and training of professionals, having experts in the ECPR procedure physically present in the hospital 24/7, as well as coordination by multidisciplinary teams from the Intensive Care Medicine, Cardiology, Cardiac Surgery and Emergency Departments and the Coordination of Donation and Transplantation Programmes of the hospital, together with the Emergency Medical System (SEM).