19, 20, 21
Standard advanced cardiac life support continued on hospital arrival
Early ECMO-facilitated resuscitation on hospital arrival, with percutaneous coronary intervention as needed
30 patients. Single centre. Open label. Stopped early for superiority, which systematically inflates effect size. Primary endpoint was survival, not neurologically favourable survival.
Adults 18–75 with out-of-hospital cardiac arrest and refractory ventricular fibrillation or pulseless VT; no ROSC after three shocks; mechanical CPR device applied; estimated transfer time under 30 minutes. Single centre, University of Minnesota; catchment 3.5 million; 18 ECPR cases per year.
Survival to hospital discharge — note this differs from the other two ECPR trials, which used neurologically favourable survival
6/14 (43%) vs 1/15 (7%); risk difference 36.2% (95% credible interval 3.7–59.2); posterior probability of ECMO superiority 0.9861. Stopped early at the first preplanned interim analysis on DSMB recommendation after 30 of a planned 174 patients. Mean low-flow time 59 min; mean on-scene time 23 min; door-to-ECMO 12 min. 80% (12/15) of the ECPR arm actually received ECPR; no crossover in the control arm.
Nothing about non-shockable rhythms, nothing about lower-volume or multicentre settings, and nothing about long transfer distances. It cannot be used to predict what a new programme will achieve — INCEPTION is the trial for that question.
ECPR has efficacy under near-ideal conditions: one high-volume centre, one team, one rhythm, mandatory mechanical compressions, a short transfer ceiling, and in-hospital randomisation so that the only difference between arms is the addition of ECPR. This is the strongest single effect estimate in the ECPR literature.