Reply to: “eCPR challenge: navigating the fine line between life and burden”

To the editor,

We appreciate Rajsic and Breitkopf [1] for their thoughtful commentary on our recent article describing sub-phenotypes in patients with out-of-hospital cardiac arrest (OHCA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR) [2]. We fully agree with their central point that neurologically favorable survival must be the primary outcome of interest when evaluating ECPR. Indeed, as we reported, one-month neurological outcome, defined by the cerebral performance category (CPC), was included as a secondary endpoint in our analysis. Our findings showed that only a minority of patients achieved favorable neurological recovery, underscoring the importance of refining patient selection.

Several recent studies provide additional perspective on the long-term outcomes of ECPR. In the INCEPTION randomized trial, favorable neurological survival at 30 days was 20% in the ECPR group compared with 16% in the conventional CPR group, with no significant difference between arms. Six-month outcomes were similar, with 20% maintaining good neurological function [3]. A large meta-analysis reported overall survival of 29% and favorable neurological outcomes in 24% of ECPR patients [4]. More encouragingly, long-term follow-up data indicate that approximately one in five patients achieve one-year survival with preserved cardiac function and independence, with many returning to meaningful daily life [5, 6]. These results suggest that, while early mortality is common, carefully selected patients can achieve durable neurological and functional recovery.

Our study differs from prior investigations by focusing on latent sub-phenotypes. We demonstrated that ECPR outcomes are not uniform: the “standard eCPR” group achieved a survival of nearly 27%, while other subgroups had far lower rates [2]. This heterogeneity may partly explain discrepancies between registries and trials. In Japan, there is concern that ECPR may be applied too liberally, potentially exposing patients with limited potential for recovery to invasive interventions and prolonged intensive care. Identifying favorable sub-phenotypes therefore represents an important step toward defining which patients are most likely to benefit.

Nonetheless, we acknowledge that the concerns highlighted in the commentary—ethical dilemmas, socioeconomic burden, and the emotional toll on families—cannot be dismissed. Initiation of ECPR is usually undertaken without explicit patient consent, and the resulting outcomes may not align with individual values. Families are often left to face not only the decision of life-sustaining treatment withdrawal but also long-term caregiving responsibilities, which may impose profound psychological and financial strain. These realities remind us that survival alone is insufficient as a benchmark for success.

In conclusion, we appreciate the opportunity to respond to these important reflections. We agree that future research must extend beyond short-term survival to systematically evaluate long-term neurological outcomes, quality of life, and family impact. Our study contributes to this evolving conversation by highlighting the need for phenotype-specific approaches to ECPR. We hope that ongoing dialogue and further prospective studies will help balance the promise of ECPR with its ethical, societal, and human costs.

No datasets were generated or analysed during the current study.

CPC:

Cerebral Performance Category

CPR:

Cardiopulmonary Resuscitation

ECPR:

Extracorporeal Cardiopulmonary Resuscitation

ICU:

Intensive Care Unit

OHCA:

Out-of-Hospital Cardiac Arrest

1. Rajsic S, Breitkopf R. eCPR challenge: navigating the fine line between life and burden. Crit Care. 2025;29:375. https://doi.org/10.1186/s13054-025-05625-y.

   Article PubMed PubMed Central Google Scholar

2. Kashiura M, Kishihara Y, Tamura H, et al. Sub-phenotypes in patients with out-of-hospital cardiac arrest who undergo extracorporeal cardiopulmonary resuscitation: a retrospective observational study from a multicenter registry. Crit Care. 2025;29:316. https://doi.org/10.1186/s13054-025-05575-5.

   Article PubMed PubMed Central Google Scholar

3. Suverein MM, Delnoij TSR, Lorusso R, et al. Early extracorporeal CPR for refractory out-of-hospital cardiac arrest. N Engl J Med. 2023;388(4):299–309. https://doi.org/10.1056/NEJMoa2204511.

   Article PubMed Google Scholar

4. Migdady I, Rice C, Deshpande A, et al. Brain injury and neurologic outcome in patients undergoing extracorporeal cardiopulmonary resuscitation: A systematic review and Meta-Analysis. Crit Care Med. 2020;48(7):e611–9. https://doi.org/10.1097/CCM.0000000000004377.

   Article PubMed Google Scholar

5. Khoury J, Soumagnac T, Vimpere D, et al. Long-Term heart function in refractory Out-of-Hospital cardiac arrest treated with prehospital ECPR. Resuscitation. 2025;207:110449. https://doi.org/10.1016/j.resuscitation.2024.110449.

   Article PubMed Google Scholar

6. Guenther SPW, Hornung R, Joskowiak D, et al. Extracorporeal life support in therapy-refractory cardiocirculatory failure: looking beyond 30 days. Interact Cardiovasc Thorac Surg. 2021;32(4):607–15. https://doi.org/10.1093/icvts/ivaa312.

   Article PubMed Google Scholar

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Authors and Affiliations

1. Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, 330-8503, Saitama, Japan

   Masahiro Kashiura, Yuki Kishihara, Hiroyuki Tamura, Hideto Yasuda & Takashi Moriya

2. Division of Emergency and Transport Services, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan

   Shunsuke Amagasa

3. Department of Clinical Research Education and Training Unit, Keio University Hospital Clinical and Translational Research Center (CTR), Shinanomachi 35, Shinjuku-ku, Tokyo, 160-8582, Japan

   Hideto Yasuda

4. School of Nursing, Midwifery and Social Work, Centre for Clinical Research, The University of Queensland, Building 71/918, Royal Brisbane & Women’s Hospital Campus, Herston, UQ, QLD, 4029, Australia

   Hideto Yasuda

5. School of Nursing and Midwifery, Alliance for Vascular Access Teaching and Research, Griffith University, Nathan, QLD, 4111, Australia

   Hideto Yasuda

Authors

1. Masahiro KashiuraView author publications

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MK drafted the initial manuscript. All authors revised and approved the final draft.

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Correspondence to Masahiro Kashiura.

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Kashiura, M., Kishihara, Y., Tamura, H. et al. Reply to: “eCPR challenge: navigating the fine line between life and burden”. Crit Care 29, 401 (2025). https://doi.org/10.1186/s13054-025-05658-3

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• Received: 02 September 2025

• Accepted: 04 September 2025

• Published: 25 September 2025

• DOI: https://doi.org/10.1186/s13054-025-05658-3

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