EBM Consult

Extracorporeal Cardiopulmonary Resuscitation vs Conventional Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest


  • P = Adult patients presenting with out-of -hospital cardiac arrest (OHCA) from presumed cardiac etiology
  • I  = Extracorporeal cardiopulmonary resuscitation (ECPR)
  • C = Conventional cardiopulmonary resuscitation (CCPR)
  • O = Survival to discharge with favorable neurological outcome
  • T = Acute Setting  
  • S = Pre-Hospital and Emergency Department

: PICOTS stands for (P) for patient, (I) for intervention of interest, (C) for comparison, (O) for outcome of interest, (T) for timing, & (S) for setting.

Take Home Point(s)

  • ECPR for OHCA is a controversial intervention due to conflicting observational studies and the lack of randomized controlled trials.
  • ECPR outperforms CCPR only when combined with reperfusion therapies and should be viewed as a bridge to definitive treatment for cardiac arrest from reversible cardiac etiologies.
  • ECPR for OHCA appears to offer mortality benefit and positive neurologic outcomes in a very select patient population when combined with a comprehensive definitive care plan that includes reperfusion techniques.
  • If a patient presents with OHCA with a broad differential diagnosis or if the etiology of cardiac arrest is known to be non-cardiac, there is little data to guide the clinical decision of initiating ECPR vs CCPR.


ECPR is an invasive and resource intense intervention for refractory OHCA. To date, there are no randomized control trials investigating differences in outcomes between ECPR and CCPR. The best available data are from observational studies that use propensity matching techniques to account for the biases inherent to this study method. A recent meta-analysis of 3 high quality observational studies published in Scientific Reports (Ahn et al., 2016) showed no statistical difference in overall survival or survival with positive neurologic outcomes between ECPR and CCPR in OHCA.  However, the conclusion of the met-analysis was largely driven by Choi et al. (2016) which found that the observed favorable neurologic outcomes of ECPR compared to CCPR were lost after controlling for reperfusion therapy and hypothermic therapy. The purpose of ECPR is to be a bridge to definitive care so it could be argued that adjusting for the impact of definitive care would be inappropriate; alternatively adjusting for this could separate out the effectiveness of individual interventions. The rate of neurologically favorable outcomes at discharge between ECPR versus CCPR in Choi et al. (2016) was 9.1% versus 1.6%, respectively. This either means that ECPR augmented the effect of definitive therapy, preserved organ function until definitive therapy was provided, or there was an unknown confounding variable accounting for the difference in positive outcomes.

In the author's interpretation of the available data, the benefits from initiating ECPR for refractory cardiac arrest are apparent for a select population demonstrating the following characteristics: less than 75 years old, witnessed cardiac arrest from cardiac etiology, signs of life upon initial evaluation, initiation of CPR within 5 minutes of cardiac arrest, and access to definitive care for a reversible cause of cardiac arrest. The decision to initiate and maintain ECPR requires multi-disciplinary care and institutional buy-in that is beyond the scope of this article.    

Author(s):  Ruben Troncoso Jr, MD, MPH and Nathan Woltman, MD - (Johns Hopkins School of Medicine)

Reviewer(s): Jeremiah Hinson, MD, PhD - (Johns Hopkins School of Medicine

Editor-in-Chief:  Anthony J. Busti, MD, PharmD, FNLA, FAHA 

Date Last Reviewed:  February 2018

Guideline Statements

  • American Heart Association, 2015
    "There is insufficient evidence to recommend the routine use of ECPR for patients with cardiac arrest. In settings where it can be rapidly implemented, ECPR may be considered for select patients for whom the suspected etiology of the cardiac arrest is potentially reversible during a limited period of mechanical cardiorespiratory support (Class IIb, LOE C-LD). Published series have used rigorous inclusion and exclusion criteria to select patients for ECPR. Although these inclusion criteria are highly variable, most included only patients aged 18 to 75 years, with arrest of cardiac origin, after conventional CPR for more than 10 minutes without ROSC. Such inclusion criteria should be considered in a provider's selection of potential candidates for ECPR."

  • European Resuscitation Council, 2015
    "Extracorporeal CPR (eCPR) should be considered as a rescue therapy for those patients in whom initial ALS measures are unsuccessful and, or to facilitate specific interventions (e.g. coronary angiography and percutaneous coronary intervention (PCI) or pulmonary thrombectomy for massive pulmonary embolism). There is an urgent need for randomised studies of eCPR and large eCPR registries to identify the circumstances in which it works best, establish guidelines for its use and identify the benefits, costs and risks of eCPR."

  • Extracorporeal Life Support Organization, 2013
    "AHA guidelines for CPR recommends consideration of ECMO to aid cardiopulmonary resuscitation in patients who have an easily reversible event, have had excellent CPR.   Contraindications: All contraindications to ECMO use (such as Gestational age < 34 weeks) should apply to ECPR patients. DNR orders.  Futility: Unsuccessful CPR (no return of spontaneous circulation) for 5-30 minutes. ECPR ma be indicated on prolonged CPR if good perfusion and metabolic support is documented."    

Cochrane Reviews

  • None known to be available.


  • Ahn C, Kim W, Cho Y, Choi K, Jang B, Lim T. Efficacy of extracorporeal cardiopulmonary resuscitation compared to conventional cardiopulmonary resuscitation for adult cardiac arrest patients: a systematic review and meta-analysis. Scientific Reports 2016;6:Article Number 34208.

  • Kim SJ, Kim HJ, Lee HY, Ahn HS, Lee SW. Comparing extracorporeal cardiopulmonary resuscitation with conventional cardiopulmonary resuscitation: meta-analysis. Resuscitation 2016.  doi: 10.1016/j.resuscitation.2016.01.019.

Prospective Trials

  • Maekawa K, Tanno K, Hase M, Mori K, Asai Y. Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis. Crit Care Med 2013;41:1186-1196.

  • Sakamoto T, Morimura N, Nagao K, Asai Y, Yokota H, Nara S, Hase M, Tahara Y, Atsumi T; SAVE-J Study Group. Extracorporeal cardio- pulmonary resuscitation versus conventional cardiopulmonary resus- citation in adults with out-of-hospital cardiac arrest: a prospective observational study. Resuscitation  2014;85:762-768.

Cohort Studies

  • Choi, D. S. et al. Extracorporeal life support and survival after out-of-hospital cardiac arrest in a nationwide registry: a propensity score-matched analysis. Resuscitation 2016;99:26-32.    

Review Articles

  • Ortega-Deballon I, Hornby L, Shemie SD, Bhanji F, Guadagno E. Extracorporeal resuscitation for refractory out-of-hospital cardiac arrest in adults: A systematic review of international practices and outcomes. Resuscitation 2016;101:12-20.  PMID: 26836946

  • Conrad SA, Rycus PT. Extracorporeal membrane oxygenation for refractory cardiac arrest.  Ann Card Anaesth 2017:20;Suppl S1:4-10. PMID: 28074817

Related Content


  • Extracorporeal Cardiopulmonary Resuscitation, ECPR, ECMO,  Conventional Cardiopulmonary Resuscitation, CCPR, Out of Hospital Cardiac Arrest