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For refractory out-of-hospital cardiac arrest due to ventricular arrhythmia, complex coronary artery disease is common but rapid revascularization and extracorporeal life support (ECLS) may boost survival, a single-center study suggested.

Among 62 consecutive such patients who met EMS transport criteria, a novel protocol of early transport to a cardiac catheterization laboratory for ECLS and revascularization was associated with a 42% rate of discharge alive with functionally favorable Cerebral Performance Category 1 or 2 status (26 of 62).

By comparison, the rate of functionally favorable survival was only 15.3% in a historical comparison group (OR 4.0, 95% CI 2.08-7.7), Demetris Yannopoulos, MD, of the University of Minnesota in Minneapolis, and colleagues reported in the Aug. 29 issue of the Journal of the American College of Cardiology.

The findings were in range of the 29% and 45% survival to hospital discharge rates in the SAVE-J and CHEER trials that also used ECLS and coronary intervention in resistant ventricular tachycardia or fibrillation. By comparison, a Japanese study on later treatment strategies for patients with return of spontaneous circulation had a 1-month neurologically intact survival of no better than 3%.

Yannopoulos's study was notable too for "unprecedented achievement" in hitting "phenomenal 6-min door-to-ECLS-initiation and 12-min door-to-balloon times," Pier Lambiase, MD, PhD, of University College London, wrote in an accompanying editorial.

This scenario of refractory ventricular fibrillation accounts for only 0.9% of all cardiac arrests, though, and the treatments described are resource-intensive, he cautioned.

"Although Yannopoulos et al are to be congratulated, from a practical perspective, the greatest gains will currently be from investment in ensuring immediate CPR and defibrillation in <5 min for the >0.5 million cardiac arrests per annum in Europe and the United States, where the numbers saved will be the greatest (approximately 50,000 versus 450 lives with ECLS and PCI for refractory VF, assuming only 20% are witnessed)."

The current priority should be links 1 to 3 -- early access to emergency medical care, early CPR, and early defibrillation -- in the American Heart Association's "chain of survival" concept, Lambiase argued. "Our challenge is to ensure that every dollar is spent to save the maximum number of lives when literally every minute counts."

Yannopoulos's study included 72 consecutive adult patients with refractory out-of-hospital ventricular fibrillation or ventricular tachycardia cardiac arrest requiring ongoing cardiopulmonary resuscitation transported by emergency medical services to the cardiac cath lab over a 1-year period.

Only 62 met criteria for transport there based on factors like no known noncardiac etiology, such as trauma or overdose; failure to respond to three EMS-delivered direct current shocks and 300 mg of intravenous or intraosseous amiodarone (Cordarone, Pacerone); anticipated transfer time of less than 30 minutes; and body morphology able to accommodate a Lund University Cardiac Arrest System (LUCAS) automated CPR device.

Of the 62, 89% met criteria for continuing resuscitation on cath lab arrival. Five had return of spontaneous circulation. All the rest got coronary angiography, which showed significant coronary artery disease in 84%. Most also had acute thrombotic lesions (64%). The rate of PCI was 84%, with an average of 2.7 stents deployed per patient.