Application of cardiac surgery techniques to improve the results of cardiopulmonary resuscitation after cardiac arrest: Controlled automated reperfusion of the whole body

Abstract

Central MessageThe application of cardiac surgical techniques to reduce ischemia–reperfusion injury to the whole body can be used to improve the results of cardiopulmonary resuscitation after cardiac arrest.See Commentary on page 53.Until now, the overall results (survival and neurologic outcome) of cardiopulmonary resuscitation (CPR) after cardiac arrest (CA) have been quite dismal. They have improved when compared with the outcome over the past number of decades but are still far from ideal. This is true for both out-of-hospital cardiac arrest1Virani S.S. Alonso A. Benjamin E.J. Bittencourt M.S. Callaway C.W. Carson A.P. et al.Heart Disease and Stroke Statistics—2020 update: a report from the American Heart Association.Circulation. 2020; 141: e139-e596Crossref PubMed Scopus (3517) Google Scholar,2Bougouin W. Dumas F. Lamhaut L. Marijon E. Carli P. Combes A. et al.Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study.Eur Heart J. 2020; 41: 1961-1971Crossref PubMed Scopus (86) Google Scholar and in-hospital cardiac arrest.3Perkins G.D. Gräsner J.-T. Semeraro F. Olasveengen T. Soar J. Lott C. et al.European Resuscitation Council Guidelines 2021: executive summary.Resuscitation. 2021; 161: 1-60Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar Survival after out-of-hospital cardiac arrest is reported to be in the range of 8% to 10%2Bougouin W. Dumas F. Lamhaut L. Marijon E. Carli P. Combes A. et al.Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study.Eur Heart J. 2020; 41: 1961-1971Crossref PubMed Scopus (86) Google Scholar with neurologic damage found in many of the survivors.4Moulaert V.R.M.P. Verbunt J.A. van Heugten C.M. Wade D.T. Cognitive impairments in survivors of out-of-hospital cardiac arrest: a systematic review.Resuscitation. 2009; 80: 297-305Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar Nevertheless, all major efforts in the field of resuscitation (including CPR by laymen and professionals, improved alarm systems, and better medications) are more than valued and have resulted in some very favorable outcomes.The pathophysiologic mechanism of injury after CA is ischemia reperfusion, not only in vital organs but also to the whole body (Figure 1). After ischemia induced by CA, low-flow reperfusion is usually established during the first phase by CPR (basic life support and advanced life support). CPR may result in the return of spontaneous circulation or (in selected cases) in the use of extracorporeal circulation. Even if return of spontaneous circulation could be established, intermittent phases of additional CA may occur.Figure 1Development of ischemia reperfusion injury in treatments of cardiac arrest. Cardiac arrest results in whole body ischemia. A, Cardiopulmonary resuscitation (CPR) may restore minimal blood flow by chest compressions and few or no ventilation (minimal uncontrolled reperfusion; ie, unmodified blood, low flow, low pressure, minimal, or no oxygen). B, Extracorporeal CPR (eCPR) has shown beneficial effects but represents an undefined therapy approach. C, Controlled automated reperfusion of the whole body (CARL) reduces reperfusion injury by control and modification of more than 10 blood parameters and control and modification of specific reperfusion parameters (for details see Table 1).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Therefore, the reasons for the poor results of CPR after CA can be classified as:•Critical underlying disease (eg, left ventricle rupture, free ruptured thoracic aortic aneurysms, and massive cerebral bleeding),•Multimorbidities (eg, end-stage lung disease, chronic renal/liver failure, frailty, insulin-dependent diabetes, severe neurologic disorders, and end-stage cancer), and•Acute multiorgan damage after ischemia–reperfusion injury.To minimize this whole-body ischemia–reperfusion injury, we introduced the concept of controlled automated reperfusion of the whole body (CARL), which is based on cardiac surgical techniques, developed over the past 20 to 30 years (Figure 1, C). CARL was developed to reduce/avoid ischemia–reperfusion injury after CA but it has not been found to be successful in critical diseases or in multimorbid patients.Intensive work in this field has resulted in previously unknown success in myocardial protection as well as organ protection in general.5Beyersdorf F. Kirsh M. Buckberg G.D. Allen B.S. Warm glutamate/aspartate-enriched blood cardioplegic solution for perioperative sudden death.J Thorac Cardiovasc Surg. 1992; 104: 1141-1147Abstract Full Text PDF PubMed Google Scholar, 6Beyersdorf F. use of controlled reperfusion in cardiac to minimize 2009; PubMed Scopus Google Scholar, B.S. Buckberg G.D. E. arrest and reperfusion by a Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar over the past a field of in cardiac surgical techniques to the field of CA and Buckberg G.D. C. C. et resuscitation after of cardiac arrest: a field in cardiac Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar, M. F. C. T. et cardiac arrest and resuscitation by extracorporeal life outcome in an PubMed Scopus Google Scholar, Buckberg C. C. et neurologic after of cardiac arrest an extracorporeal life support for blood and PubMed Scopus Google Scholar, C. F. et after controlled automated reperfusion of the whole body arrest of to 20 Surg. PubMed Google Scholar, M. F. C. et outcome in an of cardiac arrest controlled automated reperfusion of the whole of CA PubMed Scopus Google Scholar, C. F. et of cardiac arrest in a the of for PubMed Scopus Google Scholar, C. et and after 2021; PubMed Scopus Google Scholar has of this is to the of ischemia–reperfusion injury after CA, the and for and the CARL concept is also in in in with from and the in has a in the of the ischemia of the as the organ and to ischemia reperfusion injury by and control of the reperfusion C. et and after 2021; PubMed Scopus Google Scholar have shown the of the is if reperfusion are C. F. et after controlled automated reperfusion of the whole body arrest of to 20 Surg. PubMed Google of after arrest in Full Text PDF PubMed Scopus Google J. F. et of circulation and PubMed Scopus Google more than to 20 years of has developed a CARL (Figure which to many of the in C. et and after 2021; PubMed Scopus Google Scholar reperfusion which are controlled by CARL are in Table of the controlled automated reperfusion of the whole body (CARL) B, of CARL CARL and CARL Large Image Figure ViewerDownload Hi-res image Download for controlled automated reperfusion of the whole body of to in first of reperfusion to additional PubMed Scopus Google Scholar, to specific and in Full Text PDF PubMed Scopus Google Scholar, C. F. et after controlled automated reperfusion of the whole body arrest of to 20 Surg. PubMed Google Scholar, T. in PubMed Scopus Google Scholar, P. of the PubMed Scopus Google Scholar, M. J. et in Full Text Full Text PDF PubMed Scopus Google Scholar, C. and as of PubMed Scopus Google Scholar of with to cerebral and cerebral PubMed Scopus Google C. and during in and in 1992; PubMed Scopus Google E. F. of the on in to PubMed Scopus Google Scholar with of the is only when support is by extracorporeal Allen B.S. Buckberg G.D. et after cardiac arrest: of cardiopulmonary and Thorac Surg. Full Text Full Text PDF PubMed Scopus Google Scholar to support A. and support a flow, with improved and cerebral protection in a of 2020; Full Text Full Text PDF PubMed Scopus Google Scholar to improve by the A. on of of cerebral circulation of and PubMed Scopus Google Scholar by the A. on of of cerebral circulation of and PubMed Scopus Google of on the of cerebral and PubMed Scopus Google Scholar to cerebral and M. P. on of and resuscitation after and in the Scopus Google J. of during and cardiopulmonary a study.Eur Surg. PubMed Scopus Google Scholar to cerebral and M. P. on of and resuscitation after and in the Scopus Google J. of during and cardiopulmonary a study.Eur Surg. PubMed Scopus Google Scholar to of free C. and as of PubMed Scopus Google in and damage in the PubMed Scopus Google Scholar of to support M. P. M. a to successful PubMed Scopus Google Scholar to during first 30 of reperfusion are M. P. M. a to successful PubMed Scopus Google Scholar of for or A. and support a flow, with improved and cerebral protection in a of 2020; Full Text Full Text PDF PubMed Scopus Google in and of and PubMed Scopus Google F. C. C. A. et or for cardiac arrest: a systematic and Full Text Full Text PDF Scopus Google Scholar and improve M. F. C. T. et cardiac arrest and resuscitation by extracorporeal life outcome in an PubMed Scopus Google Scholar of free to C. and as of PubMed Scopus Google in and damage in the PubMed Scopus Google M. M. T. et of injury after ischemia in with PubMed Scopus Google Scholar, and in cerebral PubMed Scopus Google Scholar, J. M. of of and on cerebral PubMed Google of to to flow and the in the M. F. C. et outcome in an of cardiac arrest controlled automated reperfusion of the whole of CA PubMed Scopus Google Buckberg G.D. C. C. et neurologic after of cardiac arrest an extracorporeal life support for blood and PubMed Scopus Google Scholar to M. P. M. a to successful PubMed Scopus Google C. F. et of cardiac arrest in a the of for PubMed Scopus Google Scholar, T. et of on cerebral blood flow and in the Thorac Surg. Full Text Full Text PDF PubMed Scopus Google Scholar, J. T. et after out-of-hospital cardiac 2021; PubMed Scopus Google Scholar, M. J.-T. F. J. C. et in with out-of-hospital cardiac arrest a and Cardiovasc PubMed Scopus Google Scholar, et arrest in a resuscitation for with PubMed Scopus Google Scholar, P. A. A. et than compared with neurologic outcome in after arrest induced to PubMed Scopus Google Scholar, E. A. et of of arrest the outcome in a of PubMed Scopus Google Scholar, M. M. of on in PubMed Scopus Google Scholar to reduce the A. on of of cerebral circulation of and PubMed Scopus Google M. F. C. et outcome in an of cardiac arrest controlled automated reperfusion of the whole of CA PubMed Scopus Google Buckberg G.D. C. C. et neurologic after of cardiac arrest an extracorporeal life support for blood and PubMed Scopus Google Scholar to flow and the in the M. F. C. et outcome in an of cardiac arrest controlled automated reperfusion of the whole of CA PubMed Scopus Google in a to the of the for this M. F. C. T. et cardiac arrest and resuscitation by extracorporeal life outcome in an PubMed Scopus Google Scholar, Buckberg C. C. et neurologic after of cardiac arrest an extracorporeal life support for blood and PubMed Scopus Google Scholar, C. F. et after controlled automated reperfusion of the whole body arrest of to 20 Surg. PubMed Google Scholar, M. F. C. et outcome in an of cardiac arrest controlled automated reperfusion of the whole of CA PubMed Scopus Google Scholar, C. F. et of cardiac arrest in a the of for PubMed Scopus Google Scholar, C. et and after 2021; PubMed Scopus Google Scholar have and have resulted in a CARL which the of the CARL therapy to be in and of the controlled CARL and of the CARL (Figure This can be used the but is also to be used the in selected out-of-hospital use is in some in improve the results of CPR after CA, the use of extracorporeal circulation was introduced by the F. A. is extracorporeal cardiopulmonary Thorac PubMed Scopus Google Scholar, J. T. P. L. et of an extracorporeal resuscitation in of with 2020; PubMed Scopus Google Scholar, Alonso W. Extracorporeal cardiopulmonary resuscitation for and out-of-hospital cardiac arrest: systematic and of 2020; PubMed Google Scholar, A. T. T. Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Heart 2020; PubMed Scopus Google Scholar over CPR techniques has not been established, are the beneficial effects in selected Nevertheless, extracorporeal CPR not the of ischemia–reperfusion injury (Figure 1). based on the pathophysiologic for after C. et and after 2021; PubMed Scopus Google Scholar the CARL therapy has been developed to control a number of of which are in and of and of cardiopulmonary resuscitation extracorporeal CPR and controlled automated reperfusion of the whole body (CARL) after out-of-hospital cardiac and blood blood and not blood in a of this are very A. F. C. T. M. et automated reperfusion of the whole body after of cardiopulmonary first PubMed Scopus Google Scholar, C. F. Controlled automated reperfusion of the whole body after cardiac Thorac PubMed Scopus Google Scholar, T. F. E. P. after of cerebral blood flow 2021; PubMed Scopus Google Scholar the of of to cerebral C. F. Controlled automated reperfusion of the whole body after cardiac Thorac PubMed Scopus Google can be the by a has to be was by the and is to be in the to application of cardiac surgical techniques and to reduce after CA has shown in has been to and to improve results after This has to the application of in have shown very of is and of a of the and are and of is a of and to of and to or for which may have a of and of this have no of application of cardiac surgical techniques to reduce ischemia–reperfusion injury to the whole body can be used to improve the results of cardiopulmonary resuscitation after cardiac arrest. application of cardiac surgical techniques to reduce ischemia–reperfusion injury to the whole body can be used to improve the results of cardiopulmonary resuscitation after cardiac arrest. Commentary on page Commentary on page now, the overall results (survival and neurologic outcome) of cardiopulmonary resuscitation (CPR) after cardiac arrest (CA) have been quite dismal. They have improved when compared with the outcome over the past number of decades but are still far from ideal. This is true for both out-of-hospital cardiac arrest1Virani S.S. Alonso A. Benjamin E.J. Bittencourt M.S. Callaway C.W. Carson A.P. et al.Heart Disease and Stroke Statistics—2020 update: a report from the American Heart Association.Circulation. 2020; 141: e139-e596Crossref PubMed Scopus (3517) Google Scholar,2Bougouin W. Dumas F. Lamhaut L. Marijon E. Carli P. Combes A. et al.Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study.Eur Heart J. 2020; 41: 1961-1971Crossref PubMed Scopus (86) Google Scholar and in-hospital cardiac arrest.3Perkins G.D. Gräsner J.-T. Semeraro F. Olasveengen T. Soar J. Lott C. et al.European Resuscitation Council Guidelines 2021: executive summary.Resuscitation. 2021; 161: 1-60Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar Survival after out-of-hospital cardiac arrest is reported to be in the range of 8% to 10%2Bougouin W. Dumas F. Lamhaut L. Marijon E. Carli P. Combes A. et al.Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study.Eur Heart J. 2020; 41: 1961-1971Crossref PubMed Scopus (86) Google Scholar with neurologic damage found in many of the survivors.4Moulaert V.R.M.P. Verbunt J.A. van Heugten C.M. Wade D.T. Cognitive impairments in survivors of out-of-hospital cardiac arrest: a systematic review.Resuscitation. 2009; 80: 297-305Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar Nevertheless, all major efforts in the field of resuscitation (including CPR by laymen and professionals, improved alarm systems, and better medications) are more than valued and have resulted in some very favorable pathophysiologic mechanism of injury after CA is ischemia reperfusion, not only in vital organs but also to the whole body (Figure 1). After ischemia induced by CA, low-flow reperfusion is usually established during the first phase by CPR (basic life support and advanced life support). CPR may result in the return of spontaneous circulation or (in selected cases) in the use of extracorporeal circulation. Even if return of spontaneous circulation could be established, intermittent phases of additional CA may the reasons for the poor results of CPR after CA can be classified as:•Critical underlying disease (eg, left ventricle rupture, free ruptured thoracic aortic aneurysms, and massive cerebral bleeding),•Multimorbidities (eg, end-stage lung disease, chronic renal/liver failure, frailty, insulin-dependent diabetes, severe neurologic disorders, and end-stage cancer), and•Acute multiorgan damage after ischemia–reperfusion minimize this whole-body ischemia–reperfusion injury, we introduced the concept of controlled automated reperfusion of the whole body (CARL), which is based on cardiac surgical techniques, developed over the past 20 to 30 years (Figure 1, C). CARL was developed to reduce/avoid ischemia–reperfusion injury after CA but it has not been found to be successful in critical diseases or in multimorbid work in this field has resulted in previously unknown success in myocardial protection as well as organ protection in general.5Beyersdorf F. Kirsh M. Buckberg G.D. Allen B.S. Warm glutamate/aspartate-enriched blood cardioplegic solution for perioperative sudden death.J Thorac Cardiovasc Surg. 1992; 104: 1141-1147Abstract Full Text PDF PubMed Google Scholar, 6Beyersdorf F. use of controlled reperfusion in cardiac to minimize 2009; PubMed Scopus Google Scholar, B.S. Buckberg G.D. E. arrest and reperfusion by a Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar over the past a field of in cardiac surgical techniques to the field of CA and Buckberg G.D. C. C. et resuscitation after of cardiac arrest: a field in cardiac Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar, M. F. C. T. et cardiac arrest and resuscitation by extracorporeal life outcome in an PubMed Scopus Google Scholar, Buckberg C. C. et neurologic after of cardiac arrest an extracorporeal life support for blood and PubMed Scopus Google Scholar, C. F. et after controlled automated reperfusion of the whole body arrest of to 20 Surg. PubMed Google Scholar, M. F. C. et outcome in an of cardiac arrest controlled automated reperfusion of the whole of CA PubMed Scopus Google Scholar, C. F. et of cardiac arrest in a the of for PubMed Scopus Google Scholar, C. et and after 2021; PubMed Scopus Google Scholar has of this is to the of ischemia–reperfusion injury after CA, the and for and the CARL concept is also in in in with from and the in has a in the of the ischemia of the as the organ and to ischemia reperfusion injury by and control of the reperfusion C. et and after 2021; PubMed Scopus Google Scholar have shown the of the is if reperfusion are C. F. et after controlled automated reperfusion of the whole body arrest of to 20 Surg. PubMed Google of after arrest in Full Text PDF PubMed Scopus Google J. F. et of circulation and PubMed Scopus Google more than to 20 years of has developed a CARL (Figure which to many of the in C. et and after 2021; PubMed Scopus Google Scholar reperfusion which are controlled by CARL are in Table for controlled automated reperfusion of the whole body of to in first of reperfusion to additional PubMed Scopus Google Scholar, to specific and in Full Text PDF PubMed Scopus Google Scholar, C. F. et after controlled automated reperfusion of the whole body arrest of to 20 Surg. PubMed Google Scholar, T. in PubMed Scopus Google Scholar, P. of the PubMed Scopus Google Scholar, M. J. et in Full Text Full Text PDF PubMed Scopus Google Scholar, C. and as of PubMed Scopus Google Scholar of with to cerebral and cerebral PubMed Scopus Google C. and during in and in 1992; PubMed Scopus Google E. F. of the on in to PubMed Scopus Google Scholar with of the is only when support is by extracorporeal Allen B.S. Buckberg G.D. et after cardiac arrest: of cardiopulmonary and Thorac Surg. Full Text Full Text PDF PubMed Scopus Google Scholar to support A. and support a flow, with improved and cerebral protection in a of 2020; Full Text Full Text PDF PubMed Scopus Google Scholar to improve by the A. on of of cerebral circulation of and PubMed Scopus Google Scholar by the A. on of of cerebral circulation of and PubMed Scopus Google of on the of cerebral and PubMed Scopus Google Scholar to cerebral and M. P. on of and resuscitation after and in the Scopus Google J. of during and cardiopulmonary a study.Eur Surg. PubMed Scopus Google Scholar to cerebral and M. P. on of and resuscitation after and in the Scopus Google J. of during and cardiopulmonary a study.Eur Surg. PubMed Scopus Google Scholar to of free C. and as of PubMed Scopus Google in and damage in the PubMed Scopus Google Scholar of to support M. P. M. a to successful PubMed Scopus Google Scholar to during first 30 of reperfusion are M. P. M. a to successful PubMed Scopus Google Scholar of for or A. and support a flow, with improved and cerebral protection in a of 2020; Full Text Full Text PDF PubMed Scopus Google in and of and PubMed Scopus Google F. C. C. A. et or for cardiac arrest: a systematic and Full Text Full Text PDF Scopus Google Scholar and improve M. F. C. T. et cardiac arrest and resuscitation by extracorporeal life outcome in an PubMed Scopus Google Scholar of free to C. and as of PubMed Scopus Google in and damage in the PubMed Scopus Google M. M. T. et of injury after ischemia in with PubMed Scopus Google Scholar, and in cerebral PubMed Scopus Google Scholar, J. M. of of and on cerebral PubMed Google of to to flow and the in the M. F. C. et outcome in an of cardiac arrest controlled automated reperfusion of the whole of CA PubMed Scopus Google Buckberg G.D. C. C. et neurologic after of cardiac arrest an extracorporeal life support for blood and PubMed Scopus Google Scholar to M. P. M. a to successful PubMed Scopus Google C. F. et of cardiac arrest in a the of for PubMed Scopus Google Scholar, T. et of on cerebral blood flow and in the Thorac Surg. Full Text Full Text PDF PubMed Scopus Google Scholar, J. T. et after out-of-hospital cardiac 2021; PubMed Scopus Google Scholar, M. J.-T. F. J. C. et in with out-of-hospital cardiac arrest a and Cardiovasc PubMed Scopus Google Scholar, et arrest in a resuscitation for with PubMed Scopus Google Scholar, P. A. A. et than compared with neurologic outcome in after arrest induced to PubMed Scopus Google Scholar, E. A. et of of arrest the outcome in a of PubMed Scopus Google Scholar, M. M. of on in PubMed Scopus Google Scholar to reduce the A. on of of cerebral circulation of and PubMed Scopus Google M. F. C. et outcome in an of cardiac arrest controlled automated reperfusion of the whole of CA PubMed Scopus Google Buckberg G.D. C. C. et neurologic after of cardiac arrest an extracorporeal life support for blood and PubMed Scopus Google Scholar to flow and the in the M. F. C. et outcome in an of cardiac arrest controlled automated reperfusion of the whole of CA PubMed Scopus Google in a to the of the for this M. F. C. T. et cardiac arrest and resuscitation by extracorporeal life outcome in an PubMed Scopus Google Scholar, Buckberg C. C. et neurologic after of cardiac arrest an extracorporeal life support for blood and PubMed Scopus Google Scholar, C. F. et after controlled automated reperfusion of the whole body arrest of to 20 Surg. PubMed Google Scholar, M. F. C. et outcome in an of cardiac arrest controlled automated reperfusion of the whole of CA PubMed Scopus Google Scholar, C. F. et of cardiac arrest in a the of for PubMed Scopus Google Scholar, C. et and after 2021; PubMed Scopus Google Scholar have and have resulted in a CARL which the of the CARL therapy to be in and of the controlled CARL and of the CARL (Figure This can be used the but is also to be used the in selected out-of-hospital use is in some in improve the results of CPR after CA, the use of extracorporeal circulation was introduced by the F. A. is extracorporeal cardiopulmonary Thorac PubMed Scopus Google Scholar, J. T. P. L. et of an extracorporeal resuscitation in of with 2020; PubMed Scopus Google Scholar, Alonso W. Extracorporeal cardiopulmonary resuscitation for and out-of-hospital cardiac arrest: systematic and of 2020; PubMed Google Scholar, A. T. T. Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Heart 2020; PubMed Scopus Google Scholar over CPR techniques has not been established, are the beneficial effects in selected Nevertheless, extracorporeal CPR not the of ischemia–reperfusion injury (Figure 1). based on the pathophysiologic for after C. et and after 2021; PubMed Scopus Google Scholar the CARL therapy has been developed to control a number of of which are in and of and of cardiopulmonary resuscitation extracorporeal CPR and controlled automated reperfusion of the whole body (CARL) after out-of-hospital cardiac and blood blood and not blood in a in in with from and the in has a in the of the ischemia of the as the organ and to ischemia reperfusion injury by and control of the reperfusion C. et and after 2021; PubMed Scopus Google Scholar have shown the of the is if reperfusion are C. F. et after controlled automated reperfusion of the whole body arrest of to 20 Surg. PubMed Google of after arrest in Full Text PDF PubMed Scopus Google J. F. et of circulation and PubMed Scopus Google Scholar After more than to 20 years of has developed a CARL (Figure which to many of the in C. et and after 2021; PubMed Scopus Google Scholar reperfusion which are controlled by CARL are in Table to the of the for this M. F. C. T. et cardiac arrest and resuscitation by extracorporeal life outcome in an PubMed Scopus Google Scholar, Buckberg C. C. et neurologic after of cardiac arrest an extracorporeal life support for blood and PubMed Scopus Google Scholar, C. F. et after controlled automated reperfusion of the whole body arrest of to 20 Surg. PubMed Google Scholar, M. F. C. et outcome in an of cardiac arrest controlled automated reperfusion of the whole of CA PubMed Scopus Google Scholar, C. F. et of cardiac arrest in a the of for PubMed Scopus Google Scholar, C. et and after 2021; PubMed Scopus Google Scholar have and have resulted in a CARL which the of the CARL therapy to be in and of the controlled CARL and of the CARL (Figure This can be used the but is also to be used the in selected out-of-hospital use is in some in improve the results of CPR after CA, the use of extracorporeal circulation was introduced by the F. A. is extracorporeal cardiopulmonary Thorac PubMed Scopus Google Scholar, J. T. P. L. et of an extracorporeal resuscitation in of with 2020; PubMed Scopus Google Scholar, Alonso W. Extracorporeal cardiopulmonary resuscitation for and out-of-hospital cardiac arrest: systematic and of 2020; PubMed Google Scholar, A. T. T. Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Heart 2020; PubMed Scopus Google Scholar over CPR techniques has not been established, are the beneficial effects in selected Nevertheless, extracorporeal CPR not the of ischemia–reperfusion injury (Figure 1). based on the pathophysiologic for after C. et and after 2021; PubMed Scopus Google Scholar the CARL therapy has been developed to control a number of of which are in and not blood of this are very A. F. C. T. M. et automated reperfusion of the whole body after of cardiopulmonary first PubMed Scopus Google Scholar, C. F. Controlled automated reperfusion of the whole body after cardiac Thorac PubMed Scopus Google Scholar, T. F. E. P. after of cerebral blood flow 2021; PubMed Scopus Google Scholar the of of to cerebral C. F. Controlled automated reperfusion of the whole body after cardiac Thorac PubMed Scopus Google can be the by a has to be was by the and is to be in the to of this are very A. F. C. T. M. et automated reperfusion of the whole body after of cardiopulmonary first PubMed Scopus Google Scholar, C. F. Controlled automated reperfusion of the whole body after cardiac Thorac PubMed Scopus Google Scholar, T. F. E. P. after of cerebral blood flow 2021; PubMed Scopus Google Scholar the of of to cerebral C. F. Controlled automated reperfusion of the whole body after cardiac Thorac PubMed Scopus Google Scholar can be the by a has to be was by the and is to be in the to application of cardiac surgical techniques and to reduce after CA has shown in has been to and to improve results after This has to the application of in have shown very of is and of a of the and are and of is a of and to of and to or for which may have a of and of this have no of application of cardiac surgical techniques and to reduce after CA has shown in has been to and to improve results after This has to the application of in have shown very

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