Peffley, Nathan D.

Abstract Background Management of acute cardiogenic shock for post-cardiotomy and post-transplant patients remains challenging. The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for circulatory support is a key intervention, yet the optimal cannulation strategy—central vs. peripheral—remains debated. This study evaluates outcomes associated with each approach to inform clinical decision-making. Methods A retrospective analysis was conducted on 319 patients who received VA-ECMO for CS intraoperatively or within 24 hours postoperatively at Mayo Clinic (2010–2023). Patients were categorized into central (n=241) and peripheral (n=78) ECMO groups. Propensity score (PS) weighting using stabilized inverse probability of treatment weighting was applied to minimize baseline imbalances. Outcomes included in-hospital mortality, bleeding requiring reoperation, limb ischemia, prolonged ventilation (>7 days), and sepsis. Results The median age at ECMO initiation was 68.5 years, with 37.3% female patients. Right ventricular (RV) dysfunction was the predominant indication for ECMO initiation (p<0.001). After PS weighting, no significant difference was observed in in-hospital mortality (49.8% vs. 44.5%, p=0.416) or other major complications between central and peripheral ECMO (see Table 1). Stroke was more frequent in central ECMO (P = 0.159), though not statistically significant. Reoperation for bleeding occurred significantly more often in central ECMO in the unweighted analysis (P = 0.047), but the difference lost statistical significance after weighting (P = 0.071). Renal failure was comparable between groups (P = 0.888). Notably, sternal infection rates were comparable between groups (P=0.921). Acute limb ischemia was more common in the peripheral group (P = 0.209). Limb ischemia associated with central ECMO was not caused by the ECMO cannulas but was instead related to concomitant use of femoral intra-aortic balloon pump. Conclusions After propensity score weighting, analysis showed no significant differences in mortality or complications between central ECMO and peripheral ECMO for post-cardiotomy and post-transplant cardiogenic shock.