Revascularization During Cardiac Arrest While Receiving Extracorporeal Life Support in Patients With Acute Myocardial Infarction

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) has allowed patients with refractory out-of-hospital cardiac arrest (OHCA) due to acute myocardial infarction (AMI) to receive primary percutaneous coronary intervention (PCI); they were previously ineligible.

Objectives: The purpose of this study was to clarify the characteristics and outcomes of patients with OHCA secondary to AMI who underwent primary PCI during refractory cardiac arrest despite ECPR.

Methods: Patients with AMI and OHCA aged ≥18 years who underwent PCI with ECPR in 2013 to 2018 were identified from a multicenter ECPR registry in Japan. The primary outcome was in-hospital mortality. We also assessed possible predictors of survival to discharge using mixed effects logistic regression to account for group differences among facilities.

Results: Among 671 patients with AMI and OHCA who underwent PCI with ECPR from 30 institutions, 251 (37%) patients had refractory cardiac arrest despite ECPR initiation and subsequently underwent primary PCI. Following coronary reperfusion, 64.9% (163/251) of patients achieved the sustained return of spontaneous circulation (ROSC), 21.1% (53/251) survived, and 10.4% (26/251) had favorable neurological status at hospital discharge. Multivariable analysis revealed that intermittent prehospital ROSC (OR: 5.22; 95% CI: 1.54-17.79), shorter time to ECPR initiation (OR: 0.89; 95% CI: 0.82-0.98), and postprocedural TIMI flow grade 3 (OR: 5.08; 95% CI: 1.50-17.22) are significantly associated with survival to hospital discharge.

Conclusions: Among patients with AMI and refractory OHCA treated with ECPR, one-third did not have sustained ROSC prior to PCI. Of those, two-thirds achieved sustained ROSC following reperfusion and one-fifth survived to discharge.