Advanced REperfusion STrategies for refractory cardiac arrest - ARREST

Nov 14, 2020
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
National Heart, Lung, and Blood Institute
Date Presented:
11/13/2020
Date Published:
11/13/2020
Date Updated:
11/14/2020
Original Posted Date:
11/14/2020
References

Contribution To Literature:

The ARREST trial showed that ECMO was superior to standard ACLS at improving survival to hospital discharge.

Description:

The goal of the trial was to evaluate extracorporeal membrane oxygenation (ECMO) initiated in the catheterization laboratory compared with standard advanced cardiac life support (ACLS) among patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation.

Study Design

  • Randomized
  • Parallel
  • Open-label

Patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation were randomized to ECMO (n = 15) versus standard ACLS (n = 15). Patients randomized to ECMO were immediately taken to the catheterization laboratory after hospital arrival. ECMO was commenced and coronary angiogram performed unless the patient was declared dead upon arrival (end-tidal CO2 <10 mm Hg, PaO2 <50 mm Hg or oxygen saturation <85%, or lactic acid >18 mmol/L). Patients who arrived to the catheterization laboratory with a pulse underwent immediate coronary angiogram and coronary revascularization, if appropriate.

  • Total number of enrollees: 30
  • Duration of follow-up: 6 months
  • Mean patient age: 59 years
  • Percentage female: 17%
  • Percentage with diabetes: 20%

Inclusion criteria:

  • Out-of-hospital cardiac arrest and refractory ventricular fibrillation or pulseless ventricular tachycardia
  • No return of spontaneous circulation after three shocks
  • Automated cardiopulmonary resuscitation with a Lund University Cardiac Arrest System
  • Estimated transfer time shorter than 30 minutes

Exclusion criteria:

  • Do not resuscitate orders
  • Blunt, penetrating, or burn-related injury
  • Drowning
  • Known overdose
  • Known pregnancy
  • Prisoner
  • Nursing home resident
  • Presence of an opt-out study bracelet
  • Unavailability of the catheterization laboratory
  • Terminal cancer
  • Contraindications to emergent angiography
  • Contrast allergies
  • Active gastrointestinal or internal bleeding

Other salient features/characteristics:

  • In the ECMO group, 80% had ECMO initiated.
  • Total number of stents placed was 2 (0.7%).

Principal Findings:

The primary outcome, survival to hospital discharge, occurred in 43% of the ECMO group compared with 7% of the standard ACLS group (posterior probability = 0.99).

Secondary outcomes:

  • Survival to 6 months: 43% of the ECMO group compared with 0% of the standard ACLS group (p = 0.0063)

Interpretation:

Among patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation, ECMO initiation in the catheterization laboratory and coronary angiogram was superior to standard ACLS. In the ECMO group, there was a low frequency of percutaneous coronary intervention. ECMO was associated with higher survival to hospital discharge and 6 months compared with standard ACLS. This trial was terminated due to the finding of survival benefit from ECMO.

Early ECMO achieves three goals: 1) normalizes perfusion; 2) allows time to identify and treat severe coronary artery disease, which is the most common cause of cardiac arrest; and 3) provides a bridge to recovery in the intensive care unit during predictable subsequent multi-organ failure.

References:

Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomized controlled trial. Lancet 2020;396:1807-16.

Presented by Dr. Demetris Yannopoulos at the American Heart Association Virtual Scientific Sessions, November 13, 2020.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: AHA20, AHA Annual Scientific Sessions, Acute Coronary Syndrome, Advanced Cardiac Life Support, Arrhythmias, Cardiac, Cardiopulmonary Resuscitation, Coronary Angiography, Extracorporeal Membrane Oxygenation, Heart Arrest, Heart Failure, Out-of-Hospital Cardiac Arrest, Patient Discharge, Reperfusion, Shock, Ventricular Fibrillation


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