Editor's Choice-Extracorporeal life support for out-of-hospital cardiac arrest: Part of a treatment bundle

In recent years, an increasing number of papers have been published on the use of extracorporeal cardiopulmonary resuscitation (ECPR) in adult patients, but, although promising results have been reported in patients with in-hospital refractory cardiac arrest supported by extracorporeal life support (ECLS), data on patients with out-of-hospital (OHCA) cardiac arrest are scarce and conflicting. The present study aims at summarizing the available evidence on the use of ECPR in adult patients with OHCA, clinically focusing on the factors most often associated with outcome in these patients. Even in the absence of randomized trials, there is growing evidence from ECLS centers documenting sound clinical benefits of ECPR in selected OHCA. According to the available evidence, three factors seem to contribute strongly to the favorable outcome of ECLS supported OHCA patients: (a) selection of patients (mainly definition of age range and a witnessed cardiac arrest); (b) the availability of an ECLS team, well skilled and experienced (to reduce time of implantation and incidence of complications); (c) a multifaceted approach to the OHCA patient (the so-called ECLS-bundle) to treat the reversible cause of CA (i.e. percutaneous coronary intervention), ensure neuroprotection (hypothermia), and maintain organ perfusion (till recovery). Taking into account the promising results of ECPR in selected OHCA patients, there is a clinical need for shared protocols to reduce differences related to the center experience and mostly to increase availability of ECLS as part of a multifaceted approach for these patients.