Pragmatic Assessment of VA-ECMO Decannulation Readiness After Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest.

BACKGROUND

Readiness for venoarterial-extracorporeal membrane oxygenation (VA-ECMO) decannulation after extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) remains poorly defined.

OBJECTIVES

The objective of the study was to identify bedside clinical variables associated with successful decannulation in OHCA patients treated with ECPR.

METHODS

Consecutive OHCA patients treated under the Minnesota Resuscitation Consortium ECPR protocol from December 2015 to March 2023 were analyzed. Hemodynamic, vasoactive medication, echocardiographic, and mechanical circulatory support variables were compared between successful and failed decannulation. Feature importance analysis was conducted using Bayesian additive regression trees and multivariable logistic regression.

RESULTS

Among 390 OHCA ECPR patients, 125 underwent VA-ECMO decannulation; 110 (88%) were successful. Failed decannulations were less likely to have been witnessed arrests (73% vs 100%; P = 0.04) and had lower rates of bystander CPR (36.4% vs 68.6%; P = 0.05). On weaning readiness assessment, left ventricular ejection fraction at lowest VA-ECMO flow (OR: 0.96; 95% CI: 0.92-0.99; P = 0.024), arterial pulsatility (OR: 0.95; 95% CI: 0.90-0.99; P = 0.027), Vasoactive inotrope score (OR: 1.16; 95%-CI: 1.04-1.32; P = 0.013) and days on VA-ECMO support (OR: 1.40; 95%-CI: 1.13-1.79; P = 0.003) were significantly associated with decannulation success. A Bayesian additive regression trees model incorporating left ventricular ejection fraction, pulsatility, vasoactive-inotrope score, predecannulation VA-ECMO flow, and concomitant intra-aortic balloon pump support predicted success with an area under the curve of 0.91.

CONCLUSIONS

Our study identifies several pragmatic variables, noninvasive and accessible at the bedside that are predictive of successful decannulation among OHCA patients undergoing ECPR. Prospective validation of a composite decannulation prediction score incorporating these variables is warranted to aid decision-making.