19, 20, 21, 22
Continued standard advanced cardiac life support on scene
Invasive strategy — mechanical compressions, intra-arrest transport to a cardiac centre, ECPR and immediate invasive assessment and treatment. The randomised unit is the whole strategy, not the circuit.
Single centre. Stopped for futility, so underpowered for the primary endpoint. Bundle intervention. A third of the ECPR arm never received ECPR.
Adults 18–65 with witnessed out-of-hospital cardiac arrest of presumed cardiac origin without ROSC; all initial rhythms (61% VF/VT, 22% asystole, 17% PEA); randomised pre-hospital after 5 minutes of unsuccessful ALS. Single centre, Prague; catchment 1.25 million; 12 ECPR cases per year in the trial arm across 92 months.
Survival with good neurological outcome (CPC 1–2) at 180 days
39 (31.5%) vs 29 (22.0%); odds ratio 1.63 (0.93–2.85); difference 9.5% (−1.3 to 20.1); P = 0.09. Stopped early for futility at 256 of a planned 285. 30-day neurological recovery 38 (30.6%) vs 24 (18.2%); OR 1.99 (1.11–3.57); P = 0.02. Bleeding 31% vs 15%. Mean low-flow 62 min (given as 61 min in the same source's text); on-scene 13 min; door-to-ECMO 12 min. 66% (82/124) of the ECPR arm received ECPR; 8% (10/132) crossover in the control arm.
It does not isolate the effect of the circuit from the effect of intra-arrest transport and immediate invasive assessment. It does not tell a low-volume centre what to expect.
Two findings matter more than the headline. The control arm did far better than designed — 22% against a presumed 10% — partly because building the invasive pathway improved on-scene logistics as well. And widening entry to non-shockable rhythms diluted the effect: about 5% survival in that subgroup against about 40% CPC 1–2 in shockable rhythms on post-hoc analysis. Among patients with neurologically intact survival after more than 45 minutes of CPR, 24 of 26 had received ECPR.