The Present and Future of eCPR with Dr Darryl Abrams

Following the discussion on ECLS in AMI and cardiogenic shock, we go on to discuss eCPR for cardiac arrest specifically. This episode was recorded live at the Critical Care Canada Forum 2024 as part of our special series on cardiac intensive care.

Our guest is Dr. Darryl Abrams, Associate Medical Director and Director of Research for the Medical ECMO Program at New York-Presbyterian/Columbia University. Dr. Abrams joins us for an in-depth discussion on the current state and future direction of extracorporeal cardiopulmonary resuscitation, or eCPR.

We dive into the complex world of eCPR in refractory cardiac arrest, starting with a breakdown of the three landmark trials that have shaped the field: the ARREST trial, the Prague OHCA trial, and the INCEPTION trial. Each study offers a unique perspective, from the dramatic early findings of ARREST to the pragmatic design of Prague OHCA and the sobering multicenter outcomes of INCEPTION.

A major theme throughout the episode is the role of system design. Dr. Abrams emphasizes the importance of minimizing low-flow time, rapid cannulation, and consistent team expertise—factors that can make or break the success of eCPR.

We also explore the ethical and practical considerations that come with rolling out such a resource-intensive intervention, including the balance between innovation and equity. Is it fair that access to eCPR may depend on geography or institutional resources? And how do we make meaningful improvements in survival when only a few centers can offer this advanced care?

The episode closes with a practical lens: how should clinicians approach building an ECMO program? What are the essential pieces that need to be in place before considering eCPR? And how do you select patients in a way that balances risk, benefit, and system capacity?

Chapters:

• Introduction and guest welcome

• Setting the scene: What is eCPR and why now?

• The ARREST trial: Small study, big impact

• The Prague OHCA trial: Early randomization, broader population

• The INCEPTION trial: Multicenter reality and negative results

• Comparing the evidence: Why do outcomes differ?

• Low-flow time and speed of cannulation

• The role of meta-analyses and what they do (and don’t) tell us

• Opportunity cost: What are we giving up to fund eCPR?

• Duration of support: How long is too long?

• Will there be another trial? Challenges of equipoise

• Building a responsible eCPR program

• Patient selection: Who qualifies and why?

• Cannulation techniques and adjunct devices

• System design: U.S. vs. Canada vs. U.K.

• Ethical concerns and access inequities

• Guidelines and final takeaways