On-Scene ECPR Doubles Survival Odds in Refractory Out-of-Hospital Cardiac Arrest

Starting extracorporeal cardiopulmonary resuscitation (ECPR) directly at the scene of an out-of-hospital cardiac arrest, rather than waiting until the patient reaches hospital, was associated with roughly double the rate of survival with favourable neurological outcome in a large French registry study published in Critical Care.

Researchers analysed a multicentric prospective registry covering 52,505 out-of-hospital cardiac arrests (OHCAs) in the Greater Paris area between May 2011 and August 2024. Of these patients, 16% were female and the median age was 50 years.

The cohort split into two treatment strategies. In 256 cases, ECPR was initiated on scene by mobile teams, while 775 patients were transported to hospital before extracorporeal support began. Survival to hospital discharge with favourable neurological outcome, defined as a Cerebral Performance Category of 1 or 2, was 13% in the on-scene group compared with 6% in the hospital-based group, a difference that was statistically significant.

A key mechanistic difference lay in timing. The interval from the start of conventional CPR to ECPR initiation was markedly shorter with the on-scene strategy: a median of 70 minutes (interquartile range 60 to 84) versus 93 minutes (interquartile range 75 to 113) for the hospital-based approach.

Because patients selected for each strategy may differ systematically in prognostic factors such as arrest characteristics and patient demographics, the investigators used multivariable regression as well as propensity score methods to adjust for established predictors of outcome. In the multivariable analysis, the on-scene ECPR strategy remained independently associated with favourable neurological outcome at discharge, with an odds ratio of 2.3 (95% confidence interval 1.4 to 3.9; P < 0.01).

The association held up under alternative statistical approaches designed to reduce selection bias. In propensity score–matched analyses, the odds ratio was 2.1 (95% confidence interval 1.1 to 4.1; P = 0.03), and inverse probability of treatment weighting yielded an odds ratio of 2.3 (95% confidence interval 1.4 to 3.9; P < 0.01). Beyond discharge, at one year of follow-up the on-scene strategy was significantly associated with overall survival, as assessed by the log-rank test (P < 0.01).

Refractory out-of-hospital cardiac arrest, meaning arrest that does not respond to standard advanced life support measures, is almost invariably fatal, which is why ECPR has attracted growing interest as a rescue therapy for highly selected patients.

The authors emphasise that these observational findings highlight the potential interest of an on-scene ECPR strategy in selected patients but do not establish causation, and further investigations are warranted. Large randomised controlled trials and studies in diverse healthcare systems are needed to clarify the strategy’s role more precisely, particularly regarding long-term neurological recovery, cost-effectiveness and broader system-level impact. The registry’s single-region scope and the inherent limitations of adjusting for confounding in non-randomised treatment allocation mean the results should be interpreted as an association in a specific prehospital system rather than a definitive verdict on where ECPR should be delivered everywhere.

Subject of Research: Comparing on-scene versus hospital-based extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest

Article Title: Extracorporeal cardiopulmonary resuscitation strategies for refractory out-of-hospital cardiac arrest

Article References: Soumagnac, T., Jouven, X., Lamhaut, L., Beganton, F., Raphalen, J.-H., Cholley, B., Combes, A., Mongardon, N., Sonneville, R., Dumas, F., Jost, D., Revaux, F., Agostinucci, J.-M., Empana, J.-P., Deye, N., Cariou, A., & Bougouin, W. (2026). Extracorporeal cardiopulmonary resuscitation strategies for refractory out-of-hospital cardiac arrest. Critical Care. https://doi.org/10.1186/s13054-026-06421-y

Image Credits: AI Generated

DOI: 10.1186/s13054-026-06421-y

Keywords: ECPR, out-of-hospital cardiac arrest, refractory cardiac arrest, survival, neurological outcome, propensity score, prehospital care, ECMO, registry study, emergency medicine, resuscitation, Critical Care