Ischemic Hepatitis Before and During Venoarterial Extracorporeal Membrane Oxygenation: Associations with In-Hospital Mortality

Background: Hepatic dysfunction is associated with adverse outcomes in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, the clinical significance of ischemic hepatitis (IH) identified before versus during ECMO support remains uncertain. We investigated the association between IH categories and in-hospital outcomes in patients receiving VA-ECMO. Methods: We retrospectively analyzed 182 adult patients receiving VA-ECMO between 2019 and 2025, including 159 surgical and 23 nonsurgical patients. Patients were classified as having no IH (n = 71), pre-ECMO IH (n = 47), or on-ECMO IH (n = 64). The primary outcome was in-hospital mortality. Results: In-hospital mortality was 71.8%, 85.1%, and 89.1% in the no IH, pre-ECMO IH, and on-ECMO IH groups, respectively (overall p = 0.028). ECMO weaning success rates were 57.7%, 27.7%, and 34.4%, respectively (p = 0.002). In multivariable logistic regression adjusted for age, hypertension, baseline left ventricular ejection fraction, and estimated glomerular filtration rate, on-ECMO IH was associated with higher odds of in-hospital mortality compared with no IH (adjusted OR 4.019, 95% CI 1.453–11.112; p = 0.007). The corresponding association for pre-ECMO IH was not statistically significant (adjusted OR 2.213, 95% CI 0.785–6.241; p = 0.133). However, the direct adjusted comparison between on-ECMO IH and pre-ECMO IH was not statistically significant (adjusted OR 1.816, 95% CI 0.543–6.072; p = 0.333). Conclusions: Ischemic hepatitis identified during VA-ECMO support was associated with increased in-hospital mortality compared with the absence of IH. However, no statistically significant difference was demonstrated between pre-ECMO and on-ECMO IH. These findings should be interpreted cautiously given the retrospective classification of IH and potential temporal bias.