Extracorporeal membrane oxygenation for cardiac arrest: what, when, why, and how.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) facilitated resuscitation was first described in the 1960s, but only recently garnered increased attention with large observational studies and randomized trials evaluating its use. AREAS COVERED: In this comprehensive review of extracorporeal cardiopulmonary resuscitation (ECPR), we report the history of resuscitative ECMO, terminology, circuit configuration and cannulation considerations, complications, selection criteria, implementation and management, and important considerations for the provider. We review the relevant guidelines, different approaches to cannulation, postresuscitation management, and expected outcomes, including neurologic, cardiac, and hospital survival. Finally, we advocate for the participation in national/international Registries in order to facilitate continuous quality improvement and support scientific discovery in this evolving area. EXPERT OPINION: ECPR is the most disruptive technology in cardiac arrest resuscitation since high-quality CPR itself. ECPR has demonstrated that it can provide up to 30% increased odds of survival for refractory cardiac arrest, in tightly restricted systems and for select patients. It is also clear, though, from recent trials that ECPR will not confer this high survival when implemented in less tightly protocoled settings and within lower volume environments. Over the next 10 years, ECPR research will explore the optimal initiation thresholds, best practices for implementation, and postresuscitation care.

Revascularization Strategies in Patients with Coronary Artery Disease and Chronic Obstructive Lung Disease.

Purpose of review: This paper assesses recent literature on the impact of chronic obstructive pulmonary disease (COPD) in patients with coronary artery disease (CAD) undergoing revascularization. Specifically, to determine if there is an optimal revascularization strategy for this patient population, and if there are other modalities to assess the risks. Recent findings: There are limited new data in the last year addressing this clinical question. Recently there have been a series of studies which reinforced that COPD is a key independent risk factor for adverse outcomes after revascularization. There is no optimal revascularization strategy; however, there was a nonsignificant signal of potential benefit with percutaneous coronary intervention (PCI) with short-term outcomes in the SYNTAXES trial. Currently, pulmonary function tests (PFT) are limited in clarifying risk assessments prior to revascularization, and there are investigations into the use of biomarkers to provide further insight into this increased risk of adverse outcomes in patients with COPD. Summary: COPD is a key risk factor for poor outcomes in patients requiring revascularization. More investigations are needed to determine the optimum revascularization strategy.