The prognostic significance of complications during veno-arterial extracorporeal membrane oxygenation for cardiogenic shock

Background Veno-arterial extracorporeal oxygenation (VA ECMO) provides comprehensive circulatory support in patients with cardiogenic shock (CS) but is associated with a high incidence of complications. The relative impact of specific complications on the risk of death remains largely unknown. Methods The Extracorporeal Life Support Organization (ELSO) Registry was used to identify adult patients with CS who received VA ECMO between 2017 and 2024. For each patient, complications sustained during VA ECMO were recorded within the registry and categorized by organ system. The association between the number and type of complication and in-hospital mortality was analyzed using a Cox proportional hazards analysis. Results A total of 23,103 patients (31.7% female) were included in the study, of whom 12,442 (54%) died during index hospitalization. Complications occurred more frequently in non-survivors than survivors (74% vs 54%, p < 0.001). Neurologic complications were associated with the greatest increase in mortality (adjusted HR 3.6 [95% C.I 3.4 - 3.8] for one neurologic complication), followed by pulmonary complications (adjusted HR 2.0 [95% CI 1.8-2.2]). Across all complication categories, patients with increasing number of complications had the worst survival. Conclusion Complications on VA ECMO support have a significant and cumulative effect on in hospital mortality, with a higher number of complications portending increased risk of death. Neurologic complications are associated with the highest risk of mortality. These data may help improve risk stratification of patients receiving VA ECMO and inform discussions with patients and their families.