Daniel Rob

OBJECTIVES: A Prague out-of-hospital cardiac arrest (OHCA) study has demonstrated that an invasive approach (early transport to the hospital, extracorporeal cardiopulmonary resuscitation [ECPR]) is a feasible and effective treatment strategy in refractory OHCA. This post hoc analysis of the Prague OHCA study aimed to stratify the prognosis of patients according to the detailed course of heart rhythm during prehospital and early hospital periods. DESIGN, SETTING, AND PATIENTS: This analysis included all 256 patients (median age 58, 17% females) randomized to the Prague OHCA study. The sequence of heart rhythms during the prehospital period was analyzed in terms of neurologic outcomes after 180 days. The primary outcome was a composite of survival with Cerebral Performance Category 1 or 2 at 180 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Within the study cohort, 156 (61%) manifested ventricular fibrillation (VF), 45 pulseless electrical activity, and 55 asystole as the initial rhythm. Patients with an initial VF who reached a sustained recovery of spontaneous circulation (ROSC) had the highest proportion of reaching a primary outcome (32/44 [73%]). Patients who had one or more episodes of asystole during cardiopulmonary resuscitation had the lowest rate of primary endpoint (5/39 [13%]). Patients who experienced intermittent ROSC showed a higher success rate in achieving the primary outcome when treated with an invasive-based approach (including ECPR) compared with the conventional strategy (26/34 [76%] vs. 24/50 [48%]; p < 0.05). CONCLUSIONS: Achieving ROSC is the best prognostic marker in OHCA patients with an initially refractory VF. Patients with intermittent ROSC after the initial VF and ongoing VF seem to be optimal candidates for an invasive approach. Asystole detection at any time during resuscitation is a strong negative prognostic marker, irrespective of the initial rhythm.

Purpose of review: This article offers an overview of recent randomized controlled trials (RCTs) testing the efficacy of veno-arterial extracorporeal membrane oxygenation (VA ECMO) and microaxial flow pump (mAFP) in treating cardiogenic shock, including findings from the DanGer shock trial. It summarizes the clinical implications and limitations of these studies and key decision-making considerations for cardiogenic shock device use. Recent findings: Despite important limitations in all published RCTs, the routine use of VA ECMO for acute myocardial infarction related cardiogenic shock did not demonstrate benefit and should be reserved for selected patients with extreme forms of cardiogenic shock. Conversely, mAFP (Impella CP) appears promising for cardiogenic shock due to ST elevation myocardial infarction. A stepwise approach – initial mAFP use for cardiogenic shock with left ventricular failure, supplemented by VA ECMO if mAFP is inadequate or if severe right ventricular failure is present – may be preferable, but requires validation through RCTs. High complication rates in device arms underscore the need for careful patient selection, preventive strategies, education for centers and operators, and further research. Summary: Recent trials offer insights into mechanical circulatory support in cardiogenic shock, but their real-world applicability is limited. Despite potential benefits, the use of VA ECMO and mAFP is associated with significant complication rates, emphasizing the need for personalized use.