ARREST

Population

• Adults aged 18-75 years with out-of-hospital cardiac arrest and refractory ventricular fibrillation, no return of spontaneous circulation after three shocks, automated cardiopulmonary resuscitation, and estimated transfer time shorter than 30 minutes, presenting to the University of Minnesota Medical Center.

Intervention

Early ECMO-facilitated resuscitation.

Comparator

Standard advanced cardiac life support treatment.

Key results

• Survival to hospital discharge: 6 of 14 (43%) with early ECMO vs 1 of 15 (7%) with standard ACLS; risk difference 36.2% (95% credible interval 3.7-59.2; posterior probability of ECMO superiority 0.9861).
• The trial was stopped after 30 patients at the first preplanned interim analysis because the posterior probability of ECMO superiority exceeded the prespecified monitoring boundary.
• Cumulative 6-month survival was significantly better in the early ECMO group than in the standard ACLS group.

Harms

• No unanticipated serious adverse events were observed.

Practice impact

• Consider early ECMO-facilitated resuscitation only in systems that can select refractory VF patients and start ECMO as in this single-center pathway.

Applicability

• Most applicable to adults aged 18-75 years with refractory ventricular fibrillation, no ROSC after three shocks, mechanical CPR, and a short transfer to a center that can start ECMO on arrival.

Limitations

• This was a phase 2, single-center, open-label trial that stopped after 30 patients when a Bayesian monitoring boundary was crossed.
• Inclusion required refractory VF, no ROSC after three shocks, automated CPR, and estimated transfer time shorter than 30 minutes.
• One patient assigned to ECMO withdrew before discharge.

Common misinterpretations

• A single-center ECPR result does not generalize to all refractory out-of-hospital cardiac arrest.
• The trial compared early ECMO-facilitated resuscitation with standard ACLS, not one ECPR protocol with another.