Neurologic complications in venoarterial versus venovenous extracorporeal membrane oxygenation: A propensity score-matched retrospective cohort study.

BACKGROUND

Neurologic complications are among the most devastating events associated with extracorporeal membrane oxygenation (ECMO), yet propensity-balanced comparisons of mode-specific neurologic risk between venoarterial (VA) and venovenous (VV) configurations remain limited.

OBJECTIVES

To compare the 30-day incidence of five discrete neurologic outcomes: ischemic stroke, hemorrhagic stroke, seizures, hypoxic-ischemic encephalopathy (HIE), and brain death, between adult VA and VV ECMO patients.

METHODS

In this retrospective cohort study using the TriNetX federated network, adults undergoing VA or VV ECMO (2015-2024) were identified by ICD-10-PCS codes and 1:1 propensity score matched on demographics, comorbidities, and antithrombotic exposures. Odds ratios (OR), risk ratios, and hazard ratios (HR) with 95% confidence intervals (CI) were estimated within 30 days; multivariable Cox regression was performed for each outcome.

RESULTS

After matching (6944 per cohort), VA ECMO was associated with higher 30-day rates of cerebral infarction (7.04%vs 5.13%; OR 1.40, 95% CI 1.22-1.61), seizures (OR 1.15, 1.002-1.324), HIE (OR 2.17, 1.82-2.58), and brain death (OR 2.63, 1.67-4.14). Hemorrhagic stroke did not differ (OR 0.83, 0.66-1.04). Cox models concordantly showed higher hazard for all outcomes except hemorrhagic stroke (brain death adjusted HR 2.37, 1.58-3.57); heparin exposure was associated with lower hazard of cerebral infarction and HIE.

CONCLUSION

VA ECMO was associated with higher 30-day ischemic and hypoxic-ischemic neurologic risk than VV ECMO, while hemorrhagic risk did not differ. The hypoxic-ischemic endpoints are not separable from the indication for VA support and reflect burden rather than modality effect. These findings motivate prospective evaluation of mode-specific neurologic surveillance.