Aortic cardiopulmonary resuscitation in trauma: Extracorporeal CPR with controlled reoxygenation outperforms resuscitative thoracotomy in a porcine model of exsanguination arrest.

Abstract

Exsanguination cardiac arrest (ECA) remains a formidable challenge in trauma surgery with a persistently dismal prognosis. Extracorporeal cardiopulmonary resuscitation (ECPR) has shown promise in medical cardiac arrest and may translate to trauma. We hypothesized that aortic cardiopulmonary resuscitation in trauma (ACT)-a controlled ECPR approach aimed at mitigating reperfusion injury-would improve sustained return of spontaneous circulation (ROSC) compared with resuscitative thoracotomy (RT) in a porcine ECA model. Twelve swine were bled to mean arterial pressure <20 mm Hg and end-tidal CO2 <10 mm Hg for 1 minute, defining ECA. After 10 minutes of ECA, animals received one of two pre-assigned interventions: (1) control with RT, aortic cross-clamp, open cardiac massage, intravenous whole blood transfusion, and 100% FiO2 (n=6) or (2) ACT, involving venoarterial extracorporeal membrane oxygenation (VA-ECMO) with graded FiO2 advancement and passive hypothermia (n=6). Both groups received a 30-minute resuscitation phase followed by a 90-minute critical care phase. The primary endpoint was ROSC-defined as mean arterial pressure >50 mm Hg with a sinus rhythm-at the end of the critical care period. Secondary outcomes included coronary and carotid flow to assess critical organ perfusion during resuscitation. The primary endpoint was achieved in 100% of ACT animals versus 0% of controls (p<0.001). All subjects showed pulseless electrical activity during ECA; 6/6 controls developed ventricular fibrillation during resuscitation compared with 2/6 in ACT (p=0.060). During the critical care phase, ACT led to increased mean left-anterior-descending coronary artery flow (41.6±0.2 mL/min vs. 31.7±0.6 mL/min in RT) and right carotid artery flow (214.8±0.5 mL/min vs. 90.7±1.0 mL/min, both p<0.0001). Following ECA, ACT produced a markedly higher rate of sustained ROSC compared with conventional RT and significantly augmented coronary and carotid perfusion-highlighting its potential as a trauma-focused ECPR modality. Preclinical-large animal model.