The Present and Future of eCPR with Dr Darryl Abrams
Mar 25, 2025
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Dr. Darryl Abrams, Associate Medical Director of the Medical ECMO Program at New York-Presbyterian/Columbia University, dives into the transformative world of extracorporeal cardiopulmonary resuscitation (eCPR). He breaks down key trials like ARREST and Prague OHCA, highlighting their impact on clinical practice. The discussion covers challenges in implementing eCPR, including patient selection and ethical considerations regarding access to this advanced care. Abrams also contrasts healthcare models in the U.S. and Canada, shedding light on disparities in treatment.
The podcast discusses the impact of landmark trials like ARREST, Prague OHCA, and INCEPTION on the efficacy and implementation of eCPR in refractory cardiac arrest.
Dr. Abrams highlights the importance of system design, including minimizing low-flow time and ensuring team expertise, to enhance eCPR success rates.
Deep dives
Current Landscape of eCPR
Extracorporeal cardiopulmonary resuscitation (eCPR) has gained prominence as a potential intervention for refractory cardiac arrest, driven by a series of landmark trials that defined its efficacy. The ARREST trial was one of the first to suggest significant survival benefits from eCPR, although its small sample size and single-center design raised questions about its broader applicability. The Prague OHCA trial followed, attempting to refine eCPR implementation by randomizing patients with varied cardiac arrest rhythms shortly after the onset of arrest. This trial, however, yielded mixed results, highlighting the complexities of patient selection and the importance of rapid intervention criteria in real-world settings.
Comparative Analysis of Trials
A comparative analysis of three key trials, including the ARREST, Prague OHCA, and Inception trials, reveals differing outcomes that reflect varying methodologies and patient demographics. The ARREST trial showed promising survival rates in shockable rhythm cases, while the Prague trial, despite being larger, presented less favorable results due to a broader patient inclusion criterion that diluted potential effectiveness. Inception's findings illustrated challenges in achieving positive outcomes when treatment protocols were less strictly followed across multiple centers, as opposed to the highly controlled environments of earlier studies. These variances underscore the necessity for establishing robust protocols and experienced teams to optimize eCPR efficacy.
Systemic Considerations and Ethical Implications
The integration of eCPR into clinical practice involves careful consideration of resource allocation and patient selection, particularly in a healthcare landscape where equity and access are critical issues. There is a recognition of the opportunity costs associated with investing in eCPR resources, as hospitals must evaluate what existing services might be deprioritized to fund such high-cost interventions. Ethical dilemmas arise from disparities in access, emphasizing the need for improved standardization in conventional CPR methods across diverse healthcare settings before expanding advanced interventions like eCPR. Establishing clear criteria for patient selection, such as age limits and rhythm types, becomes essential in ensuring that eCPR is applied judiciously to maximize the lifeline it offers.
Future Directions in eCPR Research
Looking ahead, future research in eCPR may focus on pragmatic approaches to reduce low-flow times and improve patient outcomes, particularly through innovations in pre-hospital care. The use of mobile units designed specifically for eCPR could facilitate earlier interventions, though this raises questions about how best to structure trials without compromising patient selection integrity. Ongoing discussions highlight the potential for new studies to validate eCPR’s role, particularly in settings with varying levels of expertise and resources. The aim is to build a comprehensive understanding of eCPR’s efficacy while overcoming challenges related to funding, collaboration, and healthcare system structures.
Following the discussion on ECLS in AMI and cardiogenic shock, we go on to discuss eCPR for cardiac arrest specifically. This episode was recorded live at the Critical Care Canada Forum 2024 as part of our special series on cardiac intensive care.
Our guest is Dr. Darryl Abrams, Associate Medical Director and Director of Research for the Medical ECMO Program at New York-Presbyterian/Columbia University. Dr. Abrams joins us for an in-depth discussion on the current state and future direction of extracorporeal cardiopulmonary resuscitation, or eCPR.
We dive into the complex world of eCPR in refractory cardiac arrest, starting with a breakdown of the three landmark trials that have shaped the field: the ARREST trial, the Prague OHCA trial, and the INCEPTION trial. Each study offers a unique perspective, from the dramatic early findings of ARREST to the pragmatic design of Prague OHCA and the sobering multicenter outcomes of INCEPTION.
A major theme throughout the episode is the role of system design. Dr. Abrams emphasizes the importance of minimizing low-flow time, rapid cannulation, and consistent team expertise—factors that can make or break the success of eCPR.
We also explore the ethical and practical considerations that come with rolling out such a resource-intensive intervention, including the balance between innovation and equity. Is it fair that access to eCPR may depend on geography or institutional resources? And how do we make meaningful improvements in survival when only a few centers can offer this advanced care?
The episode closes with a practical lens: how should clinicians approach building an ECMO program? What are the essential pieces that need to be in place before considering eCPR? And how do you select patients in a way that balances risk, benefit, and system capacity?
Chapters:
Introduction and guest welcome
Setting the scene: What is eCPR and why now?
The ARREST trial: Small study, big impact
The Prague OHCA trial: Early randomization, broader population
The INCEPTION trial: Multicenter reality and negative results
Comparing the evidence: Why do outcomes differ?
Low-flow time and speed of cannulation
The role of meta-analyses and what they do (and don’t) tell us
Opportunity cost: What are we giving up to fund eCPR?
Duration of support: How long is too long?
Will there be another trial? Challenges of equipoise
Building a responsible eCPR program
Patient selection: Who qualifies and why?
Cannulation techniques and adjunct devices
System design: U.S. vs. Canada vs. U.K.
Ethical concerns and access inequities
Guidelines and final takeaways
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