Original Investigation
Transesophageal Echocardiography During CPR in Patients With Out-of-Hospital Cardiac Arrest: The EXECT-CPR Randomized Clinical Trial
Sheng-En Chu, Chiao-Yin Cheng, Chih-Jung Chang, et al
JAMA Intern Med Published Online: March 23, 2026
doi: 10.1001/jamainternmed.2026.0102
Question Does transesophageal echocardiography (TEE)–guided cardiopulmonary resuscitation (CPR) to target the left ventricle while avoiding the aortic valve improve clinical outcomes in adults with nontraumatic out-of-hospital cardiac arrest?
Findings In this cluster-randomized clinical trial involving 132 adults, TEE guidance yielded no significant differences in return of spontaneous circulation, survival, or neurological outcomes compared with conventional CPR. However, the TEE-guided group demonstrated significantly higher postintervention end-tidal carbon dioxide levels without increased adverse events.
Meaning In this study, emergency department–based TEE guidance for compression site adjustment did not significantly improve clinical outcomes but appeared to enhance hemodynamic efficacy without increasing harm.
Abstract
Importance Cardiopulmonary resuscitation (CPR) guidelines recommend chest compressions at the lower half of the sternum. This may lead to aortic valve compression, which is associated with poor outcomes, while compressions over the left ventricle are seldom achieved.
Objective To test the hypothesis that transesophageal echocardiography (TEE) guidance during CPR to avoid aortic valve compression and target the left ventricle would improve outcomes in patients with nontraumatic out-of-hospital cardiac arrest compared with conventional CPR.
Design, Setting, and Participants This cluster-randomized clinical trial (the EXECT-CPR study) was conducted from June 26 to November 19, 2023, at 1 tertiary medical center in Taiwan. Participants were adults who consecutively presented to the emergency department (ED) with nontraumatic out-of-hospital cardiac arrest. Exclusion criteria were prehospital return of spontaneous circulation, extracorporeal CPR, contraindications to TEE, prior do-not-resuscitate orders, and obvious signs of death. Complete blinding was not feasible; the allocation schedule was disclosed only to the principal investigator.
Intervention Post–ED arrival CPR at TEE-guided (avoid aortic-valve compression and target the left ventricle) or guideline-recommended (the lower half of the sternum) site.
Main Outcomes and Measures The primary outcome was a sustained return of spontaneous circulation (≥20 minutes). Secondary outcomes were any return of spontaneous circulation, survival to intensive care unit admission, survival to hospital discharge, cerebral performance category of 2 or lower at discharge, and intra-CPR end-tidal carbon dioxide levels.
Results A total of 132 patients underwent randomization (66 in each group; median [IQR] age, 68 [55-74] years; 87 [66%] male). The primary outcome was similar between groups (TEE-guided group, 29 [44%]; conventional group, 26 [39%]; cluster-adjusted odds ratio, 1.21; 95% CI, 0.64-2.29). The secondary outcomes also did not significantly differ, except for higher intra-CPR end-tidal carbon dioxide levels in the TEE-guided group during the 11th to 20th minutes after arrival. Adverse event rates related to TEE and CPR were comparable.
Conclusions and Relevance In this randomized clinical trial among adults transported to the emergency department with ongoing CPR for nontraumatic out-of-hospital cardiac arrest, TEE-guided CPR with an adjusted compression site after arrival did not significantly improve clinical outcomes compared with conventional CPR, although it produced potential hemodynamic benefits without increasing adverse events. Given that the trial was underpowered due to optimistic effect size assumptions, these neutral findings should be interpreted with caution.
Trial Registration ClinicalTrials.gov Identifier: NCT05907460
