{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T12:14:26Z","timestamp":1790079266194,"version":"4.0.1"},"reference-count":23,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T00:00:00Z","timestamp":1790035200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100002632","name":"Hallym University","doi-asserted-by":"publisher","award":["HURF-2026-23"],"award-info":[{"award-number":["HURF-2026-23"]}],"id":[{"id":"10.13039\/501100002632","id-type":"DOI","asserted-by":"publisher"}]},{"award":["HURF-2026-23"],"award-info":[{"award-number":["HURF-2026-23"]}],"id":[{"id":"https:\/\/ror.org\/03sbhge02","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background\/Objectives: Low-flow time (LFT) is a major prognostic factor in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR), but chronological LFT may not fully reflect ischemic burden when transient return of spontaneous circulation (ROSC) occurs. We investigated whether the association between transient ROSC and outcomes varies according to LFT. Methods: This nationwide retrospective cohort study included 810 adults with witnessed out-of-hospital cardiac arrest who underwent ECPR. The primary outcome was survival to hospital discharge, and the secondary outcome was good neurological outcome. A prespecified subgroup analysis compared LFT \u226490 versus &gt;90 min, followed by an exploratory analysis using &lt;60, 60\u201390, and &gt;90 min categories. Multivariable logistic regression and interaction analyses were performed. Results: Among 810 patients, 450 (55.6%) experienced transient ROSC. In the prespecified analysis, transient ROSC was associated with survival in patients with LFT \u226490 min (adjusted odds ratio [AOR], 2.375; 95% confidence interval [CI], 1.076\u20135.241; p = 0.032), but not in those with LFT &gt;90 min (AOR, 0.884; 95% CI, 0.595\u20131.315; p = 0.543), with a significant interaction (p = 0.036). The exploratory three-category analysis showed a significant association in the 60\u201390-min subgroup (AOR, 3.399; 95% CI, 1.021\u201311.316; p = 0.046), although the global interaction was not significant (p = 0.126). No significant interaction was observed for good neurological outcome. The prespecified survival interaction remained significant in sensitivity analyses. Conclusions: The association between transient ROSC and survival after ECPR differed according to LFT using the prespecified 90-min cutoff. Transient ROSC may provide prognostic information complementary to chronological LFT, whereas the three-category findings should be considered exploratory.<\/jats:p>","DOI":"10.3390\/jcm15197354","type":"journal-article","created":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T11:09:35Z","timestamp":1790075375000},"page":"7354","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Prognostic Impact of Transient Return of Spontaneous Circulation According to Low-Flow Time in Patients with Out-of-Hospital Cardiac Arrest Undergoing Extracorporeal Cardiopulmonary Resuscitation: A Nationwide Cohort Study"],"prefix":"10.3390","volume":"15","author":[{"given":"Seongjin","family":"Noh","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2446-4497","authenticated-orcid":false,"given":"Jae-Guk","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"given":"Gu-Hyun","family":"Kang","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Yong-Soo","family":"Jang","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Wonhee","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"resources","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Hyun-Young","family":"Choi","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"resources","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"737","DOI":"10.1001\/jama.2022.1025","article-title":"Effect of intra-arrest transport, extracorporeal cardiopulmonary resuscitation, and immediate invasive assessment and treatment on functional neurologic outcome in refractory out-of-hospital cardiac arrest: A randomized clinical trial","volume":"327","author":"Belohlavek","year":"2022","journal-title":"J. Am. Med. Assoc."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"100521","DOI":"10.1016\/j.resplu.2023.100521","article-title":"Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: 10-year experience in a metropolitan cardiac arrest centre in Milan, Italy","volume":"17","author":"Scquizzato","year":"2024","journal-title":"Resusc. Plus"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/j.ajem.2023.10.024","article-title":"Low-flow time and outcomes in out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation","volume":"75","author":"Shoji","year":"2024","journal-title":"Am. J. Emerg. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1016\/j.jcrc.2018.08.006","article-title":"Low-flow time is associated with a favorable neurological outcome in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation","volume":"48","author":"Otani","year":"2018","journal-title":"J. Crit. Care"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1186\/s13054-017-1744-8","article-title":"Influence of low-flow time on survival after extracorporeal cardiopulmonary resuscitation (eCPR)","volume":"21","author":"Wengenmayer","year":"2017","journal-title":"Crit. Care"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1768","DOI":"10.1097\/CCM.0000000000005679","article-title":"Low-flow duration and outcomes of extracorporeal cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: A nationwide inpatient database study","volume":"50","author":"Ohbe","year":"2022","journal-title":"Crit. Care Med."},{"key":"ref_7","first-page":"581","article-title":"Prognostic factors for out-of-hospital cardiac arrest patients with prolonged low-flow time undergoing extracorporeal cardiopulmonary resuscitation","volume":"14","author":"Shirasaki","year":"2025","journal-title":"Eur. Heart J. Acute Cardiovasc. Care"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"100300","DOI":"10.1016\/j.resplu.2022.100300","article-title":"Transient return of spontaneous circulation related to favourable outcomes in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation: A secondary analysis of the SAVE-J II study","volume":"12","author":"Otani","year":"2022","journal-title":"Resusc. Plus"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Kim, H., Kim, J.G., Kang, G.H., Jang, Y.S., Kim, W., Choi, H.Y., and Ahn, C. (2026). Clinical impact of the transient return of spontaneous circulation before extracorporeal cardiopulmonary resuscitation in patients with refractory out-of-hospital cardiac arrest: A nationwide observational study. J. Clin. Med., 15.","DOI":"10.3390\/jcm15103584"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1097\/MAT.0000000000001344","article-title":"Extracorporeal cardiopulmonary resuscitation in adults. Interim guideline consensus statement from the extracorporeal life support organization","volume":"67","author":"Richardson","year":"2021","journal-title":"ASAIO J."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"843","DOI":"10.1016\/S2213-2600(25)00122-5","article-title":"Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest","volume":"13","author":"Supady","year":"2025","journal-title":"Lancet Respir. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1","DOI":"10.4266\/acc.2020.00080","article-title":"Role of extracorporeal cardiopulmonary resuscitation in adults","volume":"35","author":"Kim","year":"2020","journal-title":"Acute Crit. Care"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1053\/j.sodo.2024.01.007","article-title":"Missing data: Issues, concepts, methods","volume":"30","author":"Pham","year":"2024","journal-title":"Semin. Orthod."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1765","DOI":"10.1093\/aje\/kwaf284","article-title":"Resurrecting complete-case analysis: A defense","volume":"195","author":"Mathur","year":"2026","journal-title":"Am. J. Epidemiol."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Oh, H.S., Ahn, J., Ko, R.E., Yang, J.H., Cho, Y.H., and Ryu, J.A. (2026). Optimal low-flow time of extracorporeal cardiopulmonary resuscitation for favorable neurological outcomes: A risk-stratified approach. J. Clin. Med., 15.","DOI":"10.3390\/jcm15072541"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/j.ienj.2009.07.001","article-title":"Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke (Part II)","volume":"18","author":"Nolan","year":"2010","journal-title":"Int. Emerg. Nurs."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1186\/s13049-017-0440-7","article-title":"Neurological outcomes and duration from cardiac arrest to the initiation of extracorporeal membrane oxygenation in patients with out-of-hospital cardiac arrest: A retrospective study","volume":"25","author":"Yukawa","year":"2017","journal-title":"Scand. J. Trauma. Resusc. Emerg. Med."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Xu, Z., Xu, Z., Su, S., Ren, P., Huang, L., and Qi, L. (2026). Neurological outcomes and survival after prehospital ECPR: The impact of low-flow time. Front. Cardiovasc. Med., 13.","DOI":"10.3389\/fcvm.2026.1853927"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1007\/s12265-021-10195-9","article-title":"Predictors of survival and favorable neurologic outcome in patients treated with eCPR: A systematic review and meta-analysis","volume":"15","author":"Bertic","year":"2022","journal-title":"J. Cardiovasc. Transl. Res."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1186\/s13613-017-0309-y","article-title":"Prognostic indicators of survival and survival prediction model following extracorporeal cardiopulmonary resuscitation in patients with sudden refractory cardiac arrest","volume":"7","author":"Lee","year":"2017","journal-title":"Ann. Intensive Care"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Homma, T., Shibata, T., Murotani, K., Matsushima, Y., Shibao, K., Hori, K., Otsuka, M., Takasu, O., and Fukumoto, Y. (2026). Impact of transient return of spontaneous circulation and downtime on neurological outcomes following extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: A single-center retrospective study. BMC Cardiovasc. Disord., 26.","DOI":"10.1186\/s12872-026-06044-9"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"100892","DOI":"10.1016\/j.resplu.2025.100892","article-title":"Mechanical chest compression increases intrathoracic hemorrhage complications in patients receiving extracorporeal cardiopulmonary resuscitation","volume":"22","author":"Matsushima","year":"2025","journal-title":"Resusc. Plus"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"810","DOI":"10.5811\/westjem.2021.3.50932","article-title":"Effectiveness of mechanical chest compression devices over manual cardiopulmonary resuscitation: A systematic review with meta-analysis and trial sequential analysis","volume":"22","author":"Sheraton","year":"2021","journal-title":"West. J. Emerg. Med."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7354\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T11:39:11Z","timestamp":1790077151000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7354"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,22]]},"references-count":23,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2026,10]]}},"alternative-id":["jcm15197354"],"URL":"https:\/\/doi.org\/10.3390\/jcm15197354","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,22]]}}}