VA ECMO for extracorporeal cardiopulmonary resuscitation (ECPR) in adults in refractory cardiac arrest

Cardiac arrest is when normal blood circulation suddenly stops because the heart does not contract effectively. The underlying abnormal cardiac rhythms most associated with cardiac arrest are ventricular fibrillation (VF), asystole, pulseless electrical activity, and pulseless ventricular tachycardia (VT). Cardiac arrest leads to loss of consciousness, respiratory failure and, ultimately, death. Refractory cardiac arrest is defined as the lack of return of spontaneous circulation after 30 minutes of appropriate CPR, in the absence of hypothermia.

Treatment for cardiac arrest includes immediate CPR to restore the circulation and prevent subsequent brain injury. Defibrillation may be used to treat VF and pulseless VT rhythms. Standard care may also include mechanical ventilation, and medicines such as adrenaline and amiodarone. Resuscitation Council UK's 2021 resuscitation guidelines contain guidance on basic and advanced life support.

Mortality remains high and neurological outcomes from cardiac arrest remain poor, despite advances in cardiac arrest management and post-resuscitation care. Data from NHS England indicates that the ambulance service responds to around 40,000 people needing resuscitation each year.

NICE did a rapid review of the published literature on the efficacy and safety of this procedure. This comprised a comprehensive literature search and detailed review of the evidence from 11 sources, which was discussed by the committee. The evidence included 8 systematic reviews, 1 long-term randomised controlled trial follow-up study, 1 retrospective registry study, and 1 single-centre retrospective propensity-score matched study. It is presented in the summary of key evidence section in the interventional procedures overview. Other relevant literature is in the appendix of the overview.

The professional experts and the committee considered the key efficacy outcomes to be: survival with favourable neurological outcome and restoration of organ function.

The professional experts and the committee considered the key safety outcomes to be: bleeding, leg ischaemia, stroke, infection, renal failure and circuit-related complications.

Patient commentary was sought but none was received.

VA ECMO for ECPR should only be done in centres specialised in using VA ECMO for ECPR in refractory cardiac arrest.

VA ECMO for ECPR in refractory cardiac arrest is only available in a few centres.

The committee was told that there is a significant resource use associated with VA ECMO for ECPR.

VA ECMO for ECPR in refractory cardiac arrest is primarily for people with ischaemic heart disease.

Clinical experts advised that a shorter time between cardiac arrest and starting VA ECMO was associated with better outcomes.

The committee was informed that outcomes were better in younger people with fewer comorbidities.

The committee noted that the recommendations in this guidance include the use of ECMO during pregnancy or in the post-partum period.

There are few centres that specialise in using VA ECMO for ECPR in the UK. So, people in more rural areas may not have access to this intervention.

Acute heart failure in pregnancy is relatively uncommon. Women, trans men and non-binary people who are pregnant and have established chronic conditions such as diabetes or hypertension, or have congenital or acquired heart disease are at greater risk of heart failure. Pregnancy and maternity are protected characteristics under the Equality Act (2010).