19, 20, 21
Conventional CPR (standard advanced cardiac life support)
Extracorporeal CPR
A quarter to a third of the ECPR arm never received ECPR. No ECPR protocol was imposed, so practice varied. Very low per-centre volume. Underpowered for the observed effect size. The Red Book and the trialists describe the resuscitation trigger differently (three rounds of ALS versus 15 minutes).
Adults 18–70 with witnessed out-of-hospital cardiac arrest, bystander CPR, initial ventricular arrhythmia (99% VF/VT), no ROSC within 15 minutes of ALS; randomised pre-hospital. 10 centres, Netherlands; about 800,000 catchment per centre; 0.29 attempted cannulations per centre per month. 134 analysed of 160 randomised (26 excluded for not meeting criteria at hospital admission).
30-day survival with favourable neurological outcome (CPC 1–2)
14/70 (20%) vs 10/64 (16%); odds ratio 1.4 (0.5–3.5); P = 0.52. Serious adverse events per patient similar. Mean low-flow 74.7 min — the LONGEST of the three trials despite a mean on-scene time of 13 min, the shortest; hospital arrival to start of cannulation 16 min plus 20 min of cannulation. Delivery of ECPR in the ECPR arm is reported as 74% (52/70) by the trialists' comparison and 66% (46/70) by the trial group's own secondary analysis — BOTH RECORDED, NEITHER ASSERTED. Per-protocol analysis (n=81): 15% vs 9%, adjusted OR 1.9 (0.4–9.3), P = 0.393, with 84% posterior probability of any benefit and 61% of a 5% absolute risk reduction. Bayesian ITT re-analysis: absolute risk difference 3.6% (95% CrI −9.5 to 16.7), median RR 1.22 (0.59–2.51), 42% probability of a minimal clinically important difference at both 30 days and 6 months.
It does not show that ECPR is ineffective. It shows that implementing ECPR does not reproduce the results of dedicated single centres. The per-protocol and Bayesian analyses both favour ECPR without reaching conventional significance.
This is the effectiveness trial, and it is the one most hospitals should read first. Pragmatic implementation of ECPR across ten ordinary centres, without an imposed ECPR protocol, produced no detectable benefit. Critically, the excess low-flow time was generated INSIDE the hospitals — the ambulance services were as fast as those in the positive trials.