Clinical Efficacy of Extracorporeal Cardiopulmonary Resuscitation for Adults with Cardiac Arrest: Meta-Analysis with Trial Sequential Analysis

OBJECTIVE: This meta-analysis with trial sequential analysis (TSA) compared the clinical efficacy of extracorporeal cardiopulmonary resuscitation (ECPR) with conventional CPR (CCPR) for adult patients who experienced in-hospital cardiac arrest (IHCA) or out-of-hospital CA (OHCA). METHODS: A literature search was used to identify eligible publications (up to 30 July 2018) from PubMed, the Cochrane Library, the ISI Web of Knowledge, and Embase. Two investigators independently conducted the literature search, study selection, data extraction, and quality evaluation. Meta-analysis and TSA were used to analyze each outcome, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the level of evidence. The primary outcome was 30-day survival, and the secondary outcomes were 30-day neurologic outcome, 3-6 months' survival, 3-6 months' neurological outcome, 1-year survival, and 1-year neurological outcome. RESULTS: We identified 13 eligible observational studies for the final analysis. Pooled analyses showed that ECPR was associated with a significantly better 30-day survival (RR = 1.60, 95% CI = 1.25–2.06) and 30-day neurologic outcome (RR = 2.69, 95% CI = 1.63–4.46), and TSA confirmed these results. However, subgroup analysis of patients with OHCA indicated that ECPR and CCPR had similar effects on 30-day survival (RR = 1.18, 95% CI = 0.71–1.97), which was not confirmed by TSA. Analysis of OHCA patients indicated that ECPR provided a better 30-day neurological outcome (RR = 3.93, 95% CI = 1.00–15.50), but TSA did not support these results. Analysis of IHCA patients indicated that ECPR was associated with a better 30-day survival (RR 1.90, 95% CI 1.43–2.52) and 30-day neurologic outcome (RR 2.02, 95% CI 1.21–3.39), and TSA supported these results. Other subgroup analyses showed that the results were generally consistent, regardless of nation, propensity score matching, presumed etiology, whether the CA was witnessed or not, and study quality. CONCLUSIONS: Relative to CCPR, ECPR improved the survival and neurological outcome of patients who had IHCA. Compared to IHCA patients, TSA could not confirm better survival and neurologic outcome of ECPR in OHCA patients, suggesting that further studies are needed. TRIAL REGISTRATION: This trial was registered with PROSPERO (CRD42018100513) on 17 July 2018.