Extracorporeal cardiopulmonary resuscitation for pediatric in-hospital cardiac arrest in single ventricle patients: a systematic review and meta-analysis

Objectives Assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual/mechanical cardiopulmonary resuscitation (CPR), for in-hospital cardiac arrest (IHCA) in pediatric patients with single ventricle (SV) congenital heart disease (CHD). Methods PRISMA guidelines were followed with PROSPERO registration (CRD42023479671). We searched Medline, Embase, Web of Science, PubMed, and the Cochrane Library for studies published before January 23, 2025. The population included pediatric patients (<18 years old) with IHCA. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Certainty of evidence was evaluated using the GRADE framework. Outcomes included short-term and long-term survival and favorable neurological outcome. Results We identified 20 studies: 15 described ECPR in SV patients without a comparator group, and 5 compared SV ECPR patients vs. SV extracorporeal membrane oxygenation (ECMO) without ECPR (ECMO non-ECPR). Pooled synthesis for survival to hospital discharge was analyzed in 3 observational studies with 91 SV patients (pooled OR 0.66, 95% CI 0.37-1.01) and separately in 2 registry studies with 968 SV patients (OR 0.76, 95% CI 0.35-1.37 and OR 1.06, 95% CI 0.78-1.41) with very low certainty of evidence (downgraded for risk of bias and imprecision). These studies found no significant difference in survival to hospital discharge in ECPR compared to ECMO non-ECPR in pediatric SV patients. No studies were identified that compared pediatric SV patients who received ECPR vs. conventional/manual CPR. Conclusions There is no direct evidence to either support or refute the use of ECPR during IHCA in pediatric patients with SV CHD, and there is inconclusive evidence to either support or refute the use of ECPR compared to ECMO non-ECPR. Additional research is needed to address the use of ECPR in this specific cardiac population.