In-hospital cardiac arrest occurs in 3%–4% of children recovering from cardiac surgery. Nearly half of them do not survive hospital discharge, and the survivors often experience significant long-term neurodevelopmental disability (1,2). Furthermore, the increased resource utilization following cardiac arrest presents logistical and financial challenges (3).

Survival rates to hospital discharge following postcardiotomy extracorporeal membrane oxygenation (PC-ECMO) range from 40% to 60% in most pediatric studies (4). The Extracorporeal Life Support (ECLS) Organization International Summary of April 2023 delineated survival rates among different patient groups on ECLS. For pediatric cardiac patients, the survival rate was 73%, with 55% surviving to discharge or transfer; neonatal cardiac patients had a survival rate of 69%, with 44% making it to discharge or transfer. On the other hand, pediatric and neonatal extracorporeal cardiopulmonary resuscitation (E-CPR) patients demonstrated survival rates of 58% and 69%, with discharge or transfer rates of 41% and 43%, respectively (5). Survival rates may vary based on age and weight; notably, neonates, and infants weighing less than 3 kg have been reported to face a higher risk of death post-ECMO support (4). Mortality rates remain greater than 50% in patients with single ventricle palliated circulation post-ECMO support (6). Neurologic complications are more prevalent in neonates and infants, significantly escalating with extended ECMO support, especially beyond 7 days (4). Long-term survival, for instance, at one year after PC-ECMO, has been reported to be as high as 41% (7).

In this issue of Critical Care Medicine, the study by Kobayashi et al (8) explores the utilization of E-CPR as a salvaging strategy for pediatric cardiac surgical patients experiencing prolonged in-hospital cardiac arrest. Comparing survival rates between pediatric cardiac surgery patients resuscitated with E-CPR and those with conventional CPR (C-CPR) using propensity matching, the retrospective study leverages multicenter data from the American Heart Association—Get With The Guidelines—Resuscitation Registry (2008–2020). It encompasses cardiac surgical patients under 18 years of age, enduring in-hospital cardiac arrest, and receiving at least 10 minutes of CPR. Among 1,223 patients, 741 (60.6%) received C-CPR and 482 patients (39.4%) received E-CPR. The study found that the use of E-CPR increased over the study period (p < 0.001), and the duration of CPR was longer in E-CPR compared with C-CPR recipients (42 vs. 26 min, p < 0.001). E-CPR association with higher survival rates compared with C-CPR is substantial; survival rates were 40% for E-CPR recipients and 34% for C-CPR recipients, with E-CPR also correlating with higher survival rates to hospital discharge with favorable neurologic outcomes (p = 0.02).

The study highlights the potential benefits of E-CPR, especially when C-CPR exceeds an 18-minute duration, often linked to suboptimal outcomes (9). The authors use multicenter data from the American Heart Association over a decade, lending robustness to their research (10). The propensity score matching employed ensures meticulous control for potential confounding variables, further bolstered by a substantial sample size and a well-recognized registry for data extraction, accentuating the reliability of the findings. The significant increase in E-CPR application over the study period, associated with improved outcomes, presents a poignant argument for its incorporation into pediatric resuscitation protocols.

However, acknowledging the inherent limitations of the study’s retrospective and observational nature is crucial. Although the associations are compelling, establishing causality requires prospective, randomized studies for validation and further elucidation. Propensity score matching, albeit useful, cannot account for unmeasured confounding, a significant concern in observational studies.

Aligning with previous research, this study emphasizes E-CPR as a crucial component in managing pediatric cardiac arrests postsurgery. The observed survival benefit and neurologic outcome improvement reiterate findings from smaller-scale studies and case series (10). Favorable early outcomes have been similarly described in adult survivors of PC-ECMO despite the vast differences in physiology, comorbidities, and recovery potential of this patient population: survival-to-hospital discharge rates range from 16% to 52%, with fewer than 30% of the centers reporting survival-to-discharge rates above 40% (11). Long-term survival seems favorable, with the vast majority of patients still alive at 1-year follow-up. In a small cohort of high-risk patients over 70 years old, survival was 69% at 3 years, and 51% at 5 years, confirming a good postdischarge prognosis for PC-ECMO patients, even in the older patients (12). However, establishing ECMO programs demands substantial investment in financial and human resources (13). The feasibility of widespread implementation, particularly in lower-resource settings, necessitates further examination regarding training, expertise availability, and healthcare economics.

For critical care practitioners, the study highlights E-CPR as a viable resuscitative strategy post-cardiac surgery in pediatric patients, especially in prolonged CPR scenarios (≥ 10 min). Nevertheless, the potential for poorer neurologic outcomes mandates a cautious approach, ensuring E-CPR employment considers the associated risks and benefits.

The study by Kobayashi et al (8) articulately emphasizes the necessity for institutions engaged in pediatric cardiac surgery to develop and sustain dedicated ECMO programs. It advocates for systemic adoption and fine-tuning of this intervention to optimize patient outcomes. This plea for dedicated ECMO programs is not singular; multiple studies have echoed this sentiment, highlighting the importance of institutional preparedness to harness ECMO’s full potential.

In conclusion, the study accentuates the urgent need for broader E-CPR implementation in pediatric cardiac critical care, underlining the importance of ongoing research to further corroborate the findings and explore the full spectrum of E-CPR benefits and risks. The article not only contributes valuable insights to the existing literature but also paves the way for future investigations that could further refine resuscitation strategies in pediatric cardiac critical care, potentially saving many young lives in the process. The journey toward unequivocally establishing E-CPR as a standard of care in postcardiotomy pediatric cardiac arrest scenarios is far from over, but this study undeniably shortens the distance.

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