Extracorporeal cardiopulmonary resuscitation (ECPR) can improve outcomes in refractory out-of-hospital cardiac arrest (OHCA), but access is limited by geographic and system constraints. We aimed to compare the potential impact of different ECPR delivery strategies in an urban setting using simulation modeling.

We performed a Monte Carlo simulation using historical OHCA data (2015–2019) from Montreal’s sole EMS. Each of 2,000 iterations simulated 1,240 annual OHCA cases using geospatial heatmaps. Patients meeting ECPR criteria (witnessed arrest, bystander CPR, age ≤70) were included. We tested in-hospital models (2-, 3-, and 4-hospital), a rendezvous model, and two prehospital strategies: hospital-based deployment and an optimally located mobile team. Transport times were estimated using a machine learning model trained on real operational data. Outcomes included survival with favorable neurological outcome, proportion of patients achieving flow recovery at 60 minutes and low-flow time.

On average, 255 patients were included per iteration. With in-hospital ECPR delivery, increasing from 2 to 4 hospitals modestly improved CPC 1-2 survival (25.3% vs 28.0%), flow recovery at 60 minutes (69.2% vs 75.1%), and low-flow interval (-2.4 minutes. Rendezvous yielded 28.8% CPC 1-2 survival, 77.3% flow-recovery at 60 minutes and -2.9 minutes low-flow time. Prehospital strategies had the greatest impact, improving CPC 1-2 survival (39.5% and 42.0%), flow-recovery at 60 minutes (99.7% and 100%), and low-flow time (-7.8 and -12 minutes) for hospital-based and optimally placed teams respectively.

In this simulation, prehospital ECPR strategies showed the potential to increase survival, improve flow recovery at 60 minutes, and reduce low-flow times in urban OHCA.