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Melanie Cole, MS (Host): ECPR is a treatment option for patients who otherwise would face near certain death. Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're highlighting extracorporeal CPR. Joining me is Dr. Torben Becker. He's the Vice Chair of Critical Care Medicine for the Department of Emergency Medicine, Associate Professor and Director of ECPR, and he's the Executive Director of the UF Health Critical Care Organization at the University of Florida College of Medicine.

Dr. Becker, thank you so much for joining us today. I'd like you to start by briefly explaining what eCPR is and how it differs from conventional CPR. Tell us a little bit about this because this is new on the scene.

Torben K. Becker, MD, PhD: Yeah, ECPR is a technology that allows us to give patients in cardiac arrest that otherwise would have had a close to 0% chance of survival another hope at possible survival. And it uses the ECMO machine, an extracorporeal membrane oxygenation machine for patients who are in refractory cardiac arrest, and essentially allows us to put them on what is similar to a bypass machine, and allows us to take over the heart and lung function completely with that machine. Whereas CPR, traditional CPR, is much more limited in its ability to provide perfusion to their vital organs for a prolonged period of time.

Melanie Cole, MS: Tell us a little bit about UF's journey towards the ECPR program. How did this come about?

Torben K. Becker, MD, PhD: This was really driven by the recognition that cardiac arrest outcomes have not improved much over the last few decades. The two biggest innovations in the last few decades were bystander CPR and bystander defibrillation, in particular with automatic external defibrillators. But beyond that, there have been very few innovations that really made a huge dent on the still very low survival rates for cardiac arrest.

ECPR is sort of the first technology in a long time that really allows us to give those patients a chance that traditionally would not have survived, despite having relatively favorable prognostic parameters such as relatively young age, a lack of sort of chronic severe comorbidities, but who just are stuck in this cardiac arrest, and we are unable to revive and resuscitate their heart.

ECPR offers a new opportunity and hope for patients to be resuscitated who traditionally would not have survived with this sort of typical interventions that we do for cardiac arrest. And we recognize at UF Health that as a center of excellence, as a major teaching and academic hospital for the state, we needed to be at the forefront of providing good care and innovative care for cardiac arrest patients and really starting to push the envelope on what's possible in terms of resuscitating patients that a few years ago would not have had a chance at survival.

Melanie Cole, MS: Dr. Becker, I'd like you to expand. You just touched briefly on patient selection. So in what clinical situations is it typically indicated? What criteria are used to determine which patients would be candidates? And you mentioned just a few, but how do factors like age, underlying health, comorbidities, cause of cardiac arrest influence their eligibility?

Torben K. Becker, MD, PhD: Yeah, that's a very good question. And specifically, we're sort of differentiating between ECPR for patients who are already in the hospital, inpatients, and for patients who are outside of the hospital setting, so who have a cardiac arrest out in the community and an ambulance, EMS, is responding to them. The criteria vary slightly from center to center. But generally speaking, for those patients that are in cardiac arrest and typically the age range that we're looking at is for adult patients age 18 to 70, up to 75 at times. Really, what it comes down to is do they have severe chronic comorbidities that are likely to be life-limiting illnesses already, versus patients who sort of were in what they thought to be good health until that cardiac arrest actually happened?

So, the reason for that is that while ECPR is a life-saving technique, it does certainly require the body to have a certain degree of reserve to tolerate endotherapy and to be able to withstand the sometimes prolonged intensive care that is following after the therapy is instituted. So typically, we're looking at an adult in the age group of 18 to 70 to 75. We're looking at patients who had a shockable rhythm initially, and that really relates to the fact that we are looking primarily at patients with a cardiac cause. And that is because ECPR is just a bridge. It's a bridge to some sort of definitive intervention. For example, a heart cath or a cardiac surgery, or some other procedure, for example, to dissolve a blood clot. So typically, we look at patients who have an etiology that is reversible.

So to summarize it, age 18 to 70, 75, an initial shockable rhythm, a presumed cardiac cause as etiology, absence of major chronic life-limiting comorbidities. And then, there are some organizational or logistical factors that come into play as well. So, bystander CPR is something that is typically needed, and that is because ECPR keeps the heart and the lungs going, but we do need to make sure that this patient had a chance at good neurologic outcome in the first place by receiving bystander CPR shortly after the cardiac arrest before too many brain cells have died essentially.

Melanie Cole, MS: Can you walk us, Dr. Becker, through the steps after CPR has been started and after arrival in the ER? Kind of walk us through the steps for other providers to when that support is started, who makes the decision, key logistical challenges in initiating it in a time-sensitive environment.

Torben K. Becker, MD, PhD: Yeah, we have a dedicated team that is on-call 24/7. And that team can be reached by a direct phone number by both our hospital staff as well as the paramedics out in the field. If they have a patient who meets or potentially meets the criteria to be an ECPR candidate, and they contact us, and after a brief discussion of the specifics of the case, if we agree that this patient is likely to be a viable and good candidate for ECPR, we activate the full ECPR response. So, that means the physician who will sort of coordinate the care will move to the patient's bedside, as will another physician. The two of them will then also perform the actual cannulation for ECPR, which is a placement of large cannulas that essentially connect to the ECMO machine. It also requires our ECMO team, our ECMO specialists, to come in to the bedside. They come with the machine, they set up the machine, and they control the machine as the cannulation is being performed and afterwards. It also requires a very large interdisciplinary team of physicians, nurses, respiratory therapists, ECMO specialists, and many other support staff to take care of this patient immediately after the accumulation. Typically, we look at, I mentioned it earlier, what is the potential reversible cause. So, the patient may go to the cath lab, or the patient may have some other procedure performed, and then the patient goes to the intensive care unit, where further care is provided, where we continue to provide the ECMO therapy, where we allow the heart and the lungs to rest and recover and where we institute any other therapies that may be needed specific to the patient and the cause of the patient's cardiac arrest.

And then, over usually a few days, but it could be as long as a few weeks, the support of the ECMO machine is being weaned off. And in an ideal scenario, we're able to wean the ECMO machine off completely. We see that the heart has recovered and we see that a good neurological function is maintained as well.

Melanie Cole, MS: Dr. Becker, thank you for telling us about the role multidisciplinary teams play in ensuring that success of the ECPR and understanding that it's a bridge. What does current data say about survival rate neurological outcomes for patients that are treated with ECPR versus conventional CPR or other emergency measures?

Torben K. Becker, MD, PhD: Yeah. Conventional CPR, we're looking at 8% neurologically intact survival, about 15% overall survival. That means that half of the patients that survive are severely neurologically injured. With ECPR, we're looking at survival somewhere between 30 to 50, sometimes even 60%. The international average that is being reported into registry is in the range of 30-35%.

Here at UF Health, with our program so far, we have a survivor rate for both our out-of-hospital and our inpatient ECPR patients of about 60%. That is with a vast majority of these patients having survived neurologically intact, meaning that they're able to go back to every life activities after the cardiac arrest and participate back in normal activities of life.

Melanie Cole, MS: Where do you see the future of ECPR headed in terms of research policy, clinical practice? Not every center is able to incorporate this into their emergency department. So, I'd like you to speak about the future and tell us how it takes a true system of care, a center of excellence, to provide this life-saving intervention.

Torben K. Becker, MD, PhD: Yeah. There's still a lot of unanswered questions when it comes to ECPR in terms of who is the best to initiate it, who is the best to provide the care before, during, and after ECPR, and which centers are capable of providing ECPR. As I mentioned, it is very much a team effort, and it requires quite a bit of resources. This is likely something that will be limited to larger centers for at least a short-term future. We certainly see more and more data emerging on the value of ECPR. And over time, we will likely see the eligibility criteria expanding as well.

I believe that as the evidence matures and more centers are starting to do that, we will not only see the criteria or the net that is being cast being widened, but we will also see that we sort of develop a better understanding of what is truly needed for this system to be most effective for our patients. And as that step evolves, certainly, I believe we'll see some smaller hospitals sort of being able to provide ECPR as well. At this time, it certainly requires a center of excellence, a major academic center, to be able to provide this lifesaving therapy 24/7, because you do have a need to have a lot of staff in-house to be able to respond at a moment's notice and to have these significant equipment and personnel needs available at that short notice.

Melanie Cole, MS: Thank you so much, Dr. Becker. What a fascinating, enlightening interview we just had. Thank you again for joining us. And to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast. We'll see you next time. With UF Health Shands Hospital, please always remember to subscribe, rate, and review UF Health MedEd Cast on Apple Podcasts, Spotify, iHeart, and Pandora. Until next time, I'm Melanie Cole.