• Samuel Heuts, UbbenJohannes F HJFHDepartment of Anesthesiology and Pain Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands., Michal J Kawczynski, Andrea Gabrio, Martje M Suverein, DelnoijThijs S RTSRDepartment of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands., Petra Kavalkova, Daniel Rob, Arnošt Komárek, van der HorstIwan C CICCCardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands.Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands., Jos G Maessen, Demetris Yannopoulos, Jan Bělohlávek, Roberto Lorusso, and van de PollMarcel C GMCGDepartment of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.School of Nutrition and Translational Research in Metabolism, University Maastricht, Maastricht, The Netherlands..
• Department of Cardiothoracic Surgery, Maastricht University Medical Center, MUMC+), P. Debyelaan 25, 6229HX, Maastricht, The Netherlands. sam.heuts@mumc.nl.
• Crit Care. 2024 Jul 3; 28 (1): 217217.

BackgroundThe outcomes of several randomized trials on extracorporeal cardiopulmonary resuscitation (ECPR) in patients with refractory out-of-hospital cardiac arrest were examined using frequentist methods, resulting in a dichotomous interpretation of results based on p-values rather than in the probability of clinically relevant treatment effects. To determine such a probability of a clinically relevant ECPR-based treatment effect on neurological outcomes, the authors of these trials performed a Bayesian meta-analysis of the totality of randomized ECPR evidence.MethodsA systematic search was applied to three electronic databases. Randomized trials that compared ECPR-based treatment with conventional CPR for refractory out-of-hospital cardiac arrest were included. The study was preregistered in INPLASY (INPLASY2023120060). The primary Bayesian hierarchical meta-analysis estimated the difference in 6-month neurologically favorable survival in patients with all rhythms, and a secondary analysis assessed this difference in patients with shockable rhythms (Bayesian hierarchical random-effects model). Primary Bayesian analyses were performed under vague priors. Outcomes were formulated as estimated median relative risks, mean absolute risk differences, and numbers needed to treat with corresponding 95% credible intervals (CrIs). The posterior probabilities of various clinically relevant absolute risk difference thresholds were estimated.ResultsThree randomized trials were included in the analysis (ECPR, n = 209 patients; conventional CPR, n = 211 patients). The estimated median relative risk of ECPR for 6-month neurologically favorable survival was 1.47 (95%CrI 0.73-3.32) with a mean absolute risk difference of 8.7% (- 5.0; 42.7%) in patients with all rhythms, and the median relative risk was 1.54 (95%CrI 0.79-3.71) with a mean absolute risk difference of 10.8% (95%CrI - 4.2; 73.9%) in patients with shockable rhythms. The posterior probabilities of an absolute risk difference > 0% and > 5% were 91.0% and 71.1% in patients with all rhythms and 92.4% and 75.8% in patients with shockable rhythms, respectively.ConclusionThe current Bayesian meta-analysis found a 71.1% and 75.8% posterior probability of a clinically relevant ECPR-based treatment effect on 6-month neurologically favorable survival in patients with all rhythms and shockable rhythms. These results must be interpreted within the context of the reported credible intervals and varying designs of the randomized trials.RegistrationINPLASY (INPLASY2023120060, December 14th, 2023, https://doi.org/10.37766/inplasy2023.12.0060 ).© 2024. The Author(s).

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