Impact of the interval between cardiopulmonary resuscitation and veno-arterial extracorporeal membrane oxygenation on in-hospital mortality in adult patients after cardiac arrest

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can improve survival and neurological outcomes in patients with cardiac arrest. This study aimed to evaluate the association between the interval from cardiopulmonary resuscitation (CPR) initiation to VA-ECMO cannulation and in-hospital mortality in adult patients. Methods: Data from 279 adult patients who received VA-ECMO during CPR were retrospectively collected and the CPR-to-ECMO interval was stratified into tertiles: ≤14 minutes, 15–29 minutes, and >30 minutes. A multivariable logistic regression examined the relationship between the interval and in-hospital mortality, adjusting for potential confounders. Results: Among the 279 patients who underwent VA-ECMO, 179 died during hospitalization. VA-ECMO was initiated within 14 minutes in 44 patients, between 15 and 29 minutes in 52 patients, and after more than 30 minutes in 83 patients. A longer interval was independently associated with a higher risk of in-hospital mortality. Each additional minute of delay was associated with a 3% increase in mortality risk (adjusted odds ratio (aOR) 1.03; 95% confidence interval (CI), 1.01–1.04; p = 0.002). Compared to patients in the lowest tertile, those in the highest tertile had a 4.07-fold increased risk of death (aOR 4.07; 95% CI, 1.90–8.73; p < 0.001). Conclusions: In patients undergoing CPR, a shorter interval between CPR initiation and VA-ECMO cannulation was significantly associated with lower in-hospital mortality. These findings underscore the importance of minimizing delays in VA-ECMO initiation to improve survival outcomes following cardiac arrest.

Cardiopulmonary resuscitation; Interval; Veno-arterial extracorporeal membrane oxygenation; Mortality; Cardiac arrest

[1] Gong W, Yan Y, Wang X, Zheng W, Smith SC III, Fonarow GC, et al. Risk factors for in-hospital cardiac arrest in patients with ST-segment elevation myocardial infarction. Journal of the American College of Cardiology. 2022; 80: 1788–1798.

[2] Chen C, Chiu P, Tang C, Lin Y, Lee Y, How C, et al. Prognostic factors for survival outcome after in-hospital cardiac arrest: an observational study of the oriental population in Taiwan. Journal of the Chinese Medical Association. 2016; 79: 11–16.

[3] Goto Y, Funada A, Goto Y. Relationship between the duration of cardiopulmonary resuscitation and favorable neurological outcomes after out-of-hospital cardiac arrest: a prospective, nationwide, population-based cohort study. Journal of the American Heart Association. 2016; 5: e002819.

[4] Cunningham CA, Coppler PJ, Skolnik AB. The immunology of the post-cardiac arrest syndrome. Resuscitation. 2022; 179: 116–123.

[5] Ellouze O, Vuillet M, Perrot J, Grosjean S, Missaoui A, Aho S, et al. Comparable outcome of out-of-hospital cardiac arrest and in-hospital cardiac arrest treated with extracorporeal life support. Artificial Organs. 2018; 42: 15–21.

[6] Callaway CW, Soar J, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, et al. Part 4: advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2015; 132: S84–S145.

[7] Singer JL, Mosesso VN III. After the lights and sirens: patient access delay in cardiac arrest. Resuscitation. 2020; 155: 234–235.

[8] Bircher NG, Chan PS, Xu Y; American Heart Association’s Get with The Guidelines–Resuscitation Investigators. Delays in cardiopulmonary resuscitation, defibrillation, and epinephrine administration all decrease survival in in-hospital cardiac arrest. Anesthesiology. 2019; 130: 414–422.

[9] Balan P, Hsi B, Thangam M, Zhao Y, Monlezun D, Arain S, et al. The cardiac arrest survival score: a predictive algorithm for in-hospital mortality after out-of-hospital cardiac arrest. Resuscitation. 2019; 144: 46–53.

[10] Chan PS, Girotra S, Tang Y, Al-Araji R, Nallamothu BK, McNally B. Outcomes for out-of-hospital cardiac arrest in the United States during the coronavirus disease 2019 pandemic. JAMA Cardiology. 2021; 6: 296–303.

[11] Hsia RY, Huang D, Mann NC, Colwell C, Mercer MP, Dai M, et al. A US national study of the association between income and ambulance response time in cardiac arrest. JAMA Network Open. 2018; 1: e185202.

[12] Hunziker S, Bivens MJ, Cocchi MN, Miller J, Salciccioli J, Howell MD, et al. International validation of the out-of-hospital cardiac arrest score in the United States. Critical Care Medicine. 2011; 39: 1670–1674.

[13] Belohlavek J, Smalcova J, Rob D, Franek O, Smid O, Pokorna M, et al. Effect of intra-arrest transport, extracorporeal cardiopulmonary resuscitation, and immediate invasive assessment and treatment on functional neurologic outcome in refractory out-of-hospital cardiac arrest: a randomized clinical trial. JAMA. 2022; 327: 737–747.

[14] Low CJW, Ramanathan K, Ling RR, Ho MJC, Chen Y, Lorusso R, et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with cardiac arrest: a comparative meta-analysis and trial sequential analysis. The Lancet Respiratory Medicine. 2023; 11: 883–893.

[15] Schiff T, Koziatek C, Pomerantz E, Bosson N, Montgomery R, Parent B, et al. Extracorporeal cardiopulmonary resuscitation dissemination and integration with organ preservation in the USA: ethical and logistical considerations. Critical Care. 2023; 27: 144.

[16] Thiele H, Zeymer U, Akin I, Behnes M, Rassaf T, Mahabadi AA, et al; ECLS-SHOCK Investigators. Extracorporeal life support in infarct-related cardiogenic shock. New England Journal of Medicine. 2023; 389: 1286–1297.

[17] Guglin M, Zucker MJ, Bazan VM, Bozkurt B, El Banayosy A, Estep JD, et al. Venoarterial ECMO for adults. Journal of the American College of Cardiology. 2019; 73: 698–716.

[18] Sim J, Kim S, Kim H, Kang P, Kim HJ, Lee D, et al. Time to initiation of extracorporeal membrane oxygenation in conventional cardiopulmonary resuscitation affects the patient survival prognosis. Journal of Internal Medicine. 2024; 296: 350–361.

[19] Ha TS, Yang JH, Cho YH, Chung CR, Park C, Jeon K, et al. Clinical outcomes after rescue extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest. Emergency Medicine Journal. 2017; 34: 107–111.

[20] Lee H, Kim HC, Ahn C, Lee S, Hong S, Yang JH, et al. Association between timing of extracorporeal membrane oxygenation and clinical outcomes in refractory cardiogenic shock. JACC: Cardiovascular Interventions. 2021; 14: 1109–1119.

[21] Choi KH, Yang JH, Hong D, Park TK, Lee JM, Song YB, et al. Optimal timing of venoarterial-extracorporeal membrane oxygenation in acute myocardial infarction patients suffering from refractory cardiogenic shock. Circulation Journal. 2020; 84: 1502–1510.

[22] Jentzer JC, Baran DA, Kyle Bohman J, van Diepen S, Radosevich M, Yalamuri S, et al. Cardiogenic shock severity and mortality in patients receiving venoarterial extracorporeal membrane oxygenator support. European Heart Journal. Acute Cardiovascular Care. 2022; 11: 891–903.

[23] Byun E, Kang PJ, Jung SH, Park SY, Lee SA, Kwon TW, et al. Impact of extracorporeal membrane oxygenation-related complications on in-hospital mortality. PLOS ONE. 2024; 19: e0300713.

[24] Chai J, Fordyce CB, Guan M, Humphries K, Hutton J, Christenson J, et al. The association of duration of resuscitation and long-term survival and functional outcomes after out-of-hospital cardiac arrest. Resuscitation. 2023; 182: 109654.

[25] Poveda-Henao C, Valenzuela-Faccini N, Pérez-Garzón M, Mantilla-Viviescas K, Chavarro-Alfonso O, Robayo-Amortegui H. Neurological outcomes and quality of life in post-cardiac arrest patients with return of spontaneous circulation supported by ECMO: a retrospective case series. Medicine. 2023; 102: e35842.

[26] Camboni D, Philipp A, Lubnow M, Bein T, Haneya A, Diez C, et al. Support time-dependent outcome analysis for veno-venous extracorporeal membrane oxygenation. European Journal of Cardio-Thoracic Surgery. 2011; 242: 1341–1346; discussion 1346–1347.

[27] Park SB, Yang JH, Park TK, Cho YH, Sung K, Chung CR, et al. Developing a risk prediction model for survival to discharge in cardiac arrest patients who undergo extracorporeal membrane oxygenation. International Journal of Cardiology. 2014; 177: 1031–1035.

[28] Crespo-Diaz R, Kosmopoulos M, Raveendran G, Gurevich S, Yannopoulos D, Bartos JA. Effects of perfusion, coronary artery disease burden, and revascularization in establishing organized cardiac rhythm during extracorporeal cardiopulmonary resuscitation for shockable refractory out-of-hospital cardiac arrest. Journal of the American Heart Association. 2024; 13: e033907.

[29] Yannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA, 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. The Lancet. 2020; 396: 1807–1816.

[30] Hochman JS, Sleeper LA, Webb JG, Dzavik V, Buller CE, Aylward P, et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA. 2006; 295: 2511–2515.

[31] van der Lingen ACJ, Becker MAJ, Kemme MJB, Rijnierse MT, Spoormans EM, Timmer SAJ, et al. Reversible cause of cardiac arrest and secondary prevention implantable cardioverter defibrillators in patients with coronary artery disease: value of complete revascularization and LGE-CMR. Journal of the American Heart Association. 2021; 10: e019101.

[32] Nagai M, Tanaka A. A pilot study on the relationship between thermal habits, chronic inflammation, and arterial stiffness in young adults. BMC Research Notes. 2025; 18: 166.

[33] Carrara M, Herpain A, Baselli G, Ferrario M. Vascular decoupling in septic shock: the combined role of autonomic nervous system, arterial stiffness, and peripheral vascular tone. Frontiers in Physiology. 2020; 11: 594.

[34] Springer A, Dreher A, Reimers J, Kaiser L, Bahlmann E, van der Schalk H, et al. Gender disparities in patients undergoing extracorporeal cardiopulmonary resuscitation. Frontiers in Cardiovascular Medicine. 2023; 10: 1265978.

[35] Vale JD, Kantor E, Papin G, Sonneville R, Braham W, Para M, et al. Femoro-axillary versus femoro-femoral veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock: a monocentric retrospective study. Perfusion. 2025; 40: 858–868.

[36] Wang L, Yang F, Zhang S, Li C, Du Z, Rycus P, et al. Percutaneous versus surgical cannulation for femoro-femoral VA-ECMO in patients with cardiogenic shock: results from the extracorporeal life support organization registry. The Journal of Heart and Lung Transplantation. 2022; 41: 470–481.

[37] Liu Z, Yang Y, Song H, Liu W, Sun P, Lin C. Impact of independent early stage extracorporeal cardiopulmonary resuscitation in the emergency department following the establishment of an extracorporeal life support team. Heliyon. 2024; 10: e23411.

[38] Perman SM, Elmer J, Maciel CB, Uzendu A, May T, Mumma BE, et al. 2023 American Heart Association focused update on adult advanced cardiovascular life support: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2024; 149: e254–e273.

[39] Suverein MM, Delnoij T, Lorusso R, Brandon Bravo Bruinsma GJ, Otterspoor L, Elzo Kraemer CV, et al. Early extracorporeal CPR for refractory out-of-hospital cardiac arrest. The New England Journal of Medicine. 2023; 388: 299–309.

[40] Son Y, Hyun Park S, Lee Y, Lee H. Prevalence and risk factors for in-hospital mortality of adult patients on veno-arterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest: a systematic review and meta-analysis. Intensive and Critical Care Nursing. 2024; 85: 103756.

[41] Aubron C, Cheng AC, Pilcher D, Leong T, Magrin G, Cooper DJ, et al. Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: a 5-year cohort study. Critical Care. 2013; 17: R73.

[42] Bertini P, Sangalli F, Meani P, Marabotti A, Rubino A, Scolletta S, et al. Establishing an extracorporeal cardiopulmonary resuscitation program. Medicina. 2024; 60: 1979.

[43] Liu M, Zhang G, Cao Y, Li C, Shi B, Zhao M, et al. Feasibility of ultrasound-guided percutaneous axillary artery cannulation for veno-arterial extracorporeal membrane oxygenation and its effect on the recovery of spontaneous heartbeat in patients with ECPR. Alternative Therapies, Health and Medicine. 2025; 31: 192–199.

[44] Nakatsutsumi K, Endo A, Costantini TW, Takayama W, Morishita K, Otomo Y, et al. Time-saving effect of real-time ultrasound-guided cannulation for extracorporeal cardiopulmonary resuscitation: a multicenter retrospective cohort study. Resuscitation. 2023; 191: 109927.