Mechanical Circulatory Support in Advanced Cardiac Life Support

by Ina Prevalska, MD
Member, SOCCA CPC MCS Subcommittee
Washington University at St. Louis, St. Louis, MO

Ashie Kapoor, MD
Member, SOCCA
University of California - Los Angeles, Los Angeles, CA

Marisa Hernandez-Morgan, MD
Member, SOCCA CPC MCS Subcommittee
University of California - Los Angeles, Los Angeles, CA

Volume 36 | Issue 4 | Dec 2025

Introduction
The initiation of mechanical circulatory support (MCS) during cardiac arrest, also known as extracorporeal cardiopulmonary resuscitation (ECPR), is increasingly being utilized in an effort to improve rates of survival with a good neurologic outcome after cardiac arrest. It involves the initiation of V-A ECMO intra-arrest, allowing for restoration of perfusion while reversible causes are sought out and addressed1,2. It must be stressed that a successful ECPR program can only exist within a system with a high-quality chain of command, encompassing pre-arrest care, ECPR team mobilization, and high-quality intensive care post-cannulation.2

IHCA vs OHCA
Location of cardiac arrest is an important distinction given the inherent differences in recognition and response. Higher rates of an initial shockable rhythm are seen in out-of-hospital cardiac arrest (OHCA) patients, with estimates of 40% of the US and European populations3,4. However, despite this, OHCA is associated with lower survival rates than in-hospital cardiac arrest (IHCA).5,6 Evidence supporting the use of ECPR for OHCA is mixed, largely owing to differences in system performance and patient selection. The first of three randomized controlled trials studying the efficacy of ECPR for OHCA was the ARREST trial. It was stopped prematurely after demonstrating impressive superiority of ECPR over conventional ACLS for patients with refractory shockable rhythms.7 The subsequent Prague OHCA and INCEPTION trials did not show a statistically significant difference in neurologically favorable outcomes with ECPR.1,8 However, secondary analyses of these trials and several meta-analyses suggest improved survival with ECPR for OHCA when performed in highly experienced systems and in select patients with favorable prognostic factors, including young age, initial shockable rhythm, witnessed arrest, and bystander CPR9-11.

IHCA represents a different patient population than the OHCA cohort, with hypoxia being the most common etiology for cardiac arrest.12 The presenting rhythm in IHCA is also much less likely to be shockable, with only a 21.75% incidence of shockable rhythms, likely due to different etiologies of arrest and different patient substrates.12 Patients with IHCA are more likely to be witnessed and have earlier CPR. In regards to ECPR, in small studies, patients with an in-hospital arrest have a shorter time to initiation, higher wean rates, and higher rates of 30-day survival when compared to OHCA13. Perioperative cardiac arrest has been described as a distinct subset of IHCA14, with etiologies and variables that are unique to this population15. The closer hemodynamic monitoring and increased availability of resources in the perioperative space allows for faster recognition and initiation of ECPR. One retrospective study found survival to discharge in the perioperative population to be significantly higher than that of the general IHCA cohort, and associated with shorter CPR duration.16

Patient Selection
Inclusion and exclusion criteria for ECPR are program- and center-specific, with each institution determining its own criteria. Factors that are typically considered are presenting rhythm (shockable vs not), age, bystander CPR, duration of downtime, and patient comorbidities.2,17 Common elements among inclusion criteria include initial shockable rhythm, arrest to CPR time <5 minutes, arrest to ECMO flow <60 minutes, age <70 years, and absence of severe comorbidities such as end organ failure or terminal malignancy1,2,17. As previously discussed, IHCA does lend itself to shorter time to identification of arrest and more rapid ECPR, but differences in presenting rhythms as well as comorbidities may change ECPR candidacy depending on institutional practice. The RESCUE-IHCA score has been developed to predict probability of death in IHCA patients receiving ECPR18, which may help the bedside clinician with patient selection.

Cannulation: Location, Cannulators, and Summary of Approach
Given that ECPR requires time for mobilization of teams and resources, patients with short resuscitation attempts should be considered, to allow for cannulation within the 60 minute mark17. Multiple cannulating locations have been successful, including the prehospital setting, emergency department19, cardiac catheterization lab, ICU, and operating room.2,17 Percutaneous femoral cannulation via the modified seldinger technique has become the most common method, and has been successfully performed by a wide variety of clinicians including surgeons, intensivists, cardiologists, and emergency physicians.17

ACLS Modifications during ECPR
The use of MCS during ongoing resuscitation efforts requires certain modifications to the standard ACLS protocol. For example, many institutions employ devices that provide mechanical chest compressions such as the Lund University Cardiac Assist System (LUCAS) device, to limit movement of the pelvis. These devices come with their own risks, as there have been reports of pericardial effusion, fractures and intra-abdominal injuries with significant blood loss associated20. While use of a mechanical CPR device can provide reliable and consistent high-quality CPR without the risk of compressor fatigue, and may minimize the amount of time “off the chest”, a recent meta-analysis of OHCA patients showed no difference in outcomes with use of the LUCAS21. Other modifications to the ACLS algorithm include avoidance of defibrillations during cannulation in order to minimize movement while arterial and venous access is obtained and cannulas are being placed. Additionally, the code leader should be separate from the ECMO and cannulation team17 as standard resuscitation should be continued until initiation of ECMO. Judicious use of epinephrine is also recommended, particularly around the time of initiation of pump flow, to minimize abrupt hypertension when circulation is restored with ECMO flow17.

2025 AHA ACLS Guidelines
In 2025, the American Heart Association (AHA) provided updated ACLS guidelines with some changes to their recommendations regarding ECPR. Current AHA guidelines recommend ECPR “in select patients when provided within an appropriately trained and equipped system of care” (Class 2a, LOE B-R)22. The update expands on this by emphasizing careful patient selection, institutional experience, and regional coordination to optimize outcomes and minimize futility23. No specific inclusion or exclusion criteria are recommended, though the guidelines highlight the importance of maintaining consistency in patient selection and conducting periodic re-evaluation of selection criteria as new data emerge. Multiple studies have demonstrated improved patient survival in centers with higher ECPR volume,24,25 supporting the proposal of a regionalized approach to implementation. Favorable outcomes have also been associated with shorter CPR duration.26-29 The guidelines thus advocate for percutaneous, over surgical, cannulation to reduce time to initiation without increasing procedural complications.

Initial management
Once a patient is cannulated for ECPR, several modifications to post-resuscitation care should be considered. Invasive blood pressure monitoring with a right radial arterial line is recommended and can also be used for monitoring of native circulation and cerebral oxygen delivery. Optimal mean arterial pressure (MAP), oxygenation and temperature targets have not been identified. The Extracorporeal Life Support Organization (ELSO) recommends titrating vasopressors to reach a target MAP of > 60mmHg.17 Mechanical ventilator settings should target lung protection and sweep gas flow should be titrated to avoid hypocarbia with monitoring of blood gases from the right radial arterial line.

Conclusion
While there has been significant advancement and progress toward a better understanding of how and when to use MCS in ACLS, there remains much to be clarified in terms of specific application, protocols and implementation of this life saving technology.

References

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