A Korean registry target trial emulation compared ECPR initiation with no ECPR within successive windows among patients still receiving CPR after presumed cardiac out-of-hospital arrest. Among 58,668 patients, 909 received ECPR. At 15-, 30-, and 60-minute emergency-department landmarks, weighted 30-day survival was 31.0% versus 16.0%, 21.6% versus 7.2%, and 10.9% versus 3.2%, respectively. Adjusted survival differences were +15.0 percentage points (95% CI 8.0–22.0), +14.4 (10.4–18.4), and +7.7 (3.7–11.7). Neurological outcomes followed a similar pattern; an exploratory analysis found smaller survival associations with longer door-to-ECMO times, remaining statistically significant through 120 minutes.
ECPR was associated with higher 30-day survival at each landmark, including 60 minutes. These observational findings inform research on timing but do not establish a causal benefit or a treatment cutoff.
Study limitation: Despite propensity weighting and landmark comparisons, this observational emulation remains vulnerable to residual confounding; the timing-gradient analysis was exploratory.
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