Advanced REperfusion STrategies for refractory cardiac arrest - ARREST
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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