The Pre-ECPR Score: Developing and Validating a Multivariable Prediction Model for Favorable Neurological Outcomes in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation

Bengt Redfors; Anders Byttner; Daniel Bengtsson; Pia Watson; Lukas Lannemyr; Peter Lundgren; Jakob Gäbel; Araz Rawshani; Anna Henningsson

doi:10.1053/j.jvca.2024.09.009

The Pre-ECPR Score: Developing and Validating a Multivariable Prediction Model for Favorable Neurological Outcomes in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation

J Cardiothorac Vasc Anesth. 2024 Sep 17:S1053-0770(24)00605-0. doi: 10.1053/j.jvca.2024.09.009. Online ahead of print.

Authors

Bengt Redfors¹, Anders Byttner², Daniel Bengtsson³, Pia Watson², Lukas Lannemyr⁴, Peter Lundgren⁵, Jakob Gäbel⁶, Araz Rawshani⁷, Anna Henningsson⁴

Affiliations

¹ Department of Cardiothoracic Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Electronic address: bengt.redfors@vgregion.se.
² Department of Cardiothoracic Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
³ Department of Perfusion, Sahlgrenska University Hospital, Gothenburg, Sweden.
⁴ Department of Cardiothoracic Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
⁵ Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
⁶ Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
⁷ Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

PMID: 39395854
DOI: 10.1053/j.jvca.2024.09.009

Abstract

Objectives: Extracorporeal cardiopulmonary resuscitation (ECPR) can save patients with refractory cardiac arrest; however, according to recent meta-analyses, only 20% of patients achieve favorable outcomes (Modified Rankin Scale 0-3). We aimed to develop and validate an ECPR prediction model to improve patient selection.

Design: Prognostic model development and internal validation study.

Setting: Single-center study.

Participants: All 120 normothermic ECPR patients treated at Sahlgrenska University Hospital between January 2010 and October 2021.

Interventions: None.

Measurements and main results: Multivariable logistic regression was used to develop the PRognostic Evaluation of ECPR (Pre-ECPR) score. Model performance was assessed through the area under curve (AUC) and compared with the Extracorporeal Life Support Organization (ELSO) "Example of selection criteria for ECPR" for 1-year survival with favorable outcomes. The positive predictive value (PPV) was calculated. Favorable outcomes occurred in 27.5% of the patients. The Pre-ECPR score, incorporating age, no-flow/initial rhythm (a composite variable), total cardiac arrest time, signs of life, pupil dilation, regional cerebral oxygen saturation, arterial pH, and end-tidal CO₂, demonstrated an AUC of 0.87 (95% confidence interval [CI] 0.77-0.93). In internal cross-validation, the AUC of 0.79 (95% CI 0.67-0.88) significantly outperformed the ELSO criteria AUC of 0.63 (95% CI 0.54-0.72, p = 0.012). Pre-ECPR score probabilities >6.4% showed 100% sensitivity and a PPV of 40.5% for favorable outcomes.

Conclusions: The Pre-ECPR score combines multiple weighted predictors to provide a single balanced probability of favorable outcomes in ECPR patient selection. In cross-validation, it demonstrated significantly more favorable discriminatory performance than that of the ELSO criteria.

Keywords: cardiac arrest; cardiopulmonary resuscitation; decision support system, clinical; extracorporeal membrane oxygenation; hypoxia, brain; predictive value of tests.