Survival after out-of-hospital cardiac arrest (OHCA) remains poor, particularly for refractory ventricular fibrillation/ventricular tachycardia (VF/VT). Extracorporeal cardiopulmonary resuscitation (ECPR) improves outcomes when delivered within 60 minutes of low-flow time, although geographic constraints frequently extend this interval in rural settings.

We hypothesized that a Helicopter-EMS (HEMS)–facilitated, hospital-based ECPR pathway could expand rural access while preserving clinical outcomes comparable to standard ground-transport ECPR.

The FaciLItated hospital-based ECPR via Helicopter Transport (FLIGHT-to-ECPR) Study is a single-center prospective observational cohort study (August 2021–December 2025). Adults (18–75 years) with refractory VF/VT OHCA meeting Minnesota Mobile Resuscitation Consortium eligibility criteria were included. The pathway used parallel EMS and Helicopter–EMS activation with intra–arrest mechanical–CPR transport to a hospital–based ECMO center. Outcomes were compared 1:1 with a matched cohort treated under the standard ground-transport ECPR protocol, matched on low-flow time. The primary outcome was survival to discharge with favorable neurologic status (CPC 1–2).

Forty-five patients underwent FLIGHT activation; 27 (60%) received ECPR (veno-arterial ECMO during cardiac arrest). Mean age was 55.2±15.0 years; 83.7% were witnessed arrests and 69.0% received bystander CPR. Mean 9-1-1–to–hospital arrival time was 70.3±18.5 minutes; HEMS scene and flight times were 18.0±11.6 and 18.6±6.3 minutes, respectively. Among cannulated patients, low-flow time was 85.9±29.3 minutes. Overall favorable neurologic survival (CPC 1-2) was 33.3% (15/45): 25.9% (7/27) in cannulated patients and 44.4% (8/18) in non-cannulated patients achieving ROSC or meeting termination criteria. In matched ECPR patients (n=27/group), low-flow times were similar (85.9±29.3 vs. 87.1±29.2minutes; p= > 0.99), with identical favorable neurologic survival (25.9%; p= > 0.99). No differences were observed in cannulation performance, ECMO duration, or hospital length of stay.

A HEMS-facilitated, hospital-based ECPR strategy is feasible and safely expands rural access to advanced resuscitation while preserving neurologic outcomes comparable to standard ground-transport ECPR. Geography alone need not preclude ECPR when systems are optimized to maintain timely reperfusion.