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

BACKGROUND: – 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. METHODS: – 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. RESULTS: – 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). CONCLUSIONS: – 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. LEVEL OF EVIDENCE: – Preclinical—large animal model.