19, 20
Continued standard advanced cardiac life support
Invasive approach — intra-arrest transport with in-hospital ECPR initiation
Two trials only, both single-centre, both stopped early (one for superiority, one for futility). Modified intention-to-treat analysis. No funding declared.
Pooled individual patient data from the two randomised trials that compared intra-arrest transport with in-hospital ECPR initiation against continued standard ALS. 147 invasive, 139 standard. Median age 57 and 58; median resuscitation duration 58 vs 49 minutes (P = 0.17). INCEPTION is deliberately excluded because it did not test the same strategy.
180-day survival with favourable neurological outcome (CPC 1–2), modified intention to treat
45 (32.4%) vs 29 (19.7%); absolute difference 12.7% (2.6–22.7), P = 0.015. 180-day survival 47 (33.8%) vs 33 (22.4%), HR 0.59 (0.43–0.81), P = 0.0009. 30-day favourable neurological outcome 44 (31.7%) vs 24 (16.3%), absolute difference 15.4% (5.6–25.1), P = 0.003. 30-day cardiac recovery 60 (43.2%) vs 46 (31.3%), absolute difference 11.9% (0.7–23), P = 0.05. Shockable rhythms: absolute difference 18.8% (7.6–29.4), P = 0.01; HR 2.26 (1.23–4.15), P = 0.009. CPR longer than 45 minutes: HR 3.99 (1.54–10.35), P = 0.005.
It answers ARREST and PRAGUE-OHCA's question, not INCEPTION's. It does not generalise to systems unlike these two dedicated single centres, and it cannot separate the circuit from the transport and invasive-assessment components.
In centres able to deliver it, the invasive approach significantly improves 30- and 180-day neurologically favourable survival. The subgroup finding that benefit was LARGER in patients resuscitated for more than 45 minutes is the strongest published argument against a hard 60-minute cut-off.