VA-ECMO-assistierte Reanimation beim refraktären Herz-Kreislauf-Stillstand

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Eine Metaanalyse von Low et al. (2023) zeigt, dass die extrakorporale kardiopulmonale Reanimation (ECPR) gegenüber der konventionellen kardiopulmonalen Reanimation (CCPR) mit einer signifikant höheren Überlebensrate assoziiert ist. Darüber hinaus zeigten sich verbesserte neurologische Langzeitergebnisse innerhalb der ersten 90 Tage nach Verwendung der ECPR. Zudem reduziert ein höheres Zentrumsvolumen die Sterblichkeitswahrscheinlichkeit, was die Bedeutung erfahrener, spezialisierter Zentren unterstreicht.

Unterschiede zwischen außerklinischem und innerklinischem Herz-Kreislauf-Stillstand

Die Metaanalyse von Low et al. (2023) zeigt, dass ECPR bei einem IHCA vorteilhaft sein kann. Im Vergleich zur CCPR wurde bei IHCA eine signifikante Reduktion der Krankenhausmortalität mit ECPR festgestellt (OR 0,42). In der aktualisierten Metaanalyse von Low et al. (2024) konnte auch für einen OHCA eine Sterblichkeitsreduktion nachgewiesen werden (OR 0,67), was die potenzielle Wirksamkeit von ECPR in beiden Szenarien unterstreicht.

Optimierung innerklinischer Abläufe

Eine Studie von Okada et al. (2023) verdeutlicht, dass eine schnellere Kanülierung entscheidend für den Erfolg der ECPR ist. In Japan erfolgt die Kanülierung häufig in der Notaufnahme statt im Operationssaal, was die Low-Flow-Zeit bis zum Beginn der ECPR verkürzt, das Risiko von Multi-Organversagen und Hirnschäden verringert und zu besseren Überlebenschancen führt.

Zukünftige Entwicklungen

Der mobile Einsatz einer VA-ECMO (venoarterielle extrakorporale Membran-Oxygenierung) kann in ländlichen Regionen sinnvoll sein, wobei die richtige Auswahl der Patient*innen wichtig ist. Optimierte Algorithmen zur Vermeidung von „Post-Reperfusionsschäden“ könnten das Outcome verbessern.

Abstract

Extracorporeal cardiopulmonary resuscitation (ECPR) is an invasive medical intervention using mechanical circulatory support for treating cardiac arrest beyond the limits of conventional cardiopulmonary resuscitation (CCPR). ECPR uses veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to maintain organ perfusion while treating reversible causes of cardiac arrest. Commonly applied criteria to select suitable patients include witnessed cardiac arrest, early bystander CPR, and a time frame of less than 60 minutes from collapse to ECPR initiation.

A meta-analysis by Low et al. (2023), which included 11 studies with 4,595 ECPR and 4,597 CCPR patients, demonstrated that ECPR was not only associated with higher survival rates, but also better long-term neurological outcomes. Additionally, a higher number of ECPR procedures per center was linked to reduced mortality rates. A 2024 updated meta-analysis confirmed these findings and demonstrated further that ECPR significantly reduced in-hospital mortality in patients with out-of-hospital cardiac arrest (OHCA).

Further insights on this topic can be gained from the individual studies on ECPR for treatment of OHCA: In general, there are several different modalities of how ECPR can be deployed, ranging from implantation at the site of the index event vs. implantation in the hospital, and even the place of implantation in the hospital varies. However, it seems that the actual pathway of how the VA-ECMO is implanted is of lower importance, and highly depends on the local infrastructure of a given hospital (rural area vs. municipal area), while achieving the lowest possible low-flow time should be the primary goal.

The available data also shows that, despite all the advances, ECPR is still a high-risk intervention which is very demanding on the personnel and requires an abundance of resources.

Overall, ECPR is a promising therapy for patients with OHCA to improve survival with good neurological outcome, but only if applied in a highly structured and standardized way, and in carefully selected patients.

Schlüsselwörter

VA-ECMO - Herz-Kreislauf-Stillstand - Reanimation - außerklinisch - innerklinisch

Keywords

VA ECMO - cardiovascular arrest - resuscitation - out of hospital - in-hospital

Publikationsverlauf

Artikel online veröffentlicht:
21. Februar 2025

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