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Multicenter Study
. 2025 Oct 1;53(10):e2043-e2053.
doi: 10.1097/CCM.0000000000006810. Epub 2025 Aug 6.

Hyperoxia and End-Organ Complications Among Cardiogenic Shock Patients Supported by Venoarterial Extracorporeal Membrane Oxygenation

Jeffrey Wang  1   2 , Apoorva Gangavelli  1 , Joseph E Tonna  3 , J Trent Magruder  2 , Akram M Zaaqoq  4 , Suraj Yalamuri  5 , P Elliott Miller  6 , Jacob C Jentzer  5
Affiliations
Multicenter Study

Hyperoxia and End-Organ Complications Among Cardiogenic Shock Patients Supported by Venoarterial Extracorporeal Membrane Oxygenation

Jeffrey Wang et al. Crit Care Med. .

Abstract

Objectives: To investigate whether severe hyperoxia predisposes to end-organ complications and whether these complications contribute to in-hospital mortality among cardiogenic shock (CS) patients supported in venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Design: Adult patients with CS from the Extracorporeal Life Support Organization Registry between 2010 and 2023 were categorized into normoxia (Pa o2 60-150 mm Hg), mild hyperoxia (Pa o2 151-300 mm Hg), and severe hyperoxia (Pa o2 > 300 mm Hg) based on their Pa o2 at 24 hours. The primary outcome was in-hospital mortality. End-organ complications were analyzed using multivariate logistic regression models, and causal mediation analysis was performed to estimate the direct and indirect effects of hyperoxia on mortality.

Setting: Multicenter, multinational prospective cohort study.

Patients: Adults with CS supported on VA-ECMO.

Interventions: Partial pressure of oxygen at 24 hours after VA-ECMO cannulation.

Measurements/main results: A total of 10,541 patients were included (normoxia: 48.4%, mild hyperoxia: 30.0%, severe hyperoxia: 21.5%). There was higher in-hospital mortality in patients with severe hyperoxia (71.7%, adjusted OR [aOR]: 2.17; 95% CI, 1.19-2.50) and mild hyperoxia (63.8%, aOR: 1.34; 95% CI, 1.19-1.50) compared normoxia (52.7%; referent group). Severe hyperoxia was associated with more end-organ complications, which incrementally predicted higher mortality (aOR: 1.42; 95% CI, 1.25-1.61). Mediation analysis demonstrated that hyperoxia primary exerted a direct effect on mortality (86%), with contributions from neurologic (3.1%), hepatic (3.9%), renal (3.5%), and bleeding (2.3%) complications.

Conclusions: Severe hyperoxia in patients with CS receiving VA-ECMO is associated with increased mortality and more end-organ complications. However, most of the effect of severe hyperoxia on mortality occurs via direct effects, independent of end-organ complications. These findings highlight the potential direct toxicity of hyperoxia and underscore the need for strategies to optimize oxygen delivery in this critically ill population.

Keywords: cardiogenic shock; extracorporeal membrane oxygenation; hyperoxia.

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Conflict of interest statement

Dr. Tonna’s institution received funding from the National Institutes of Health (NIH); he disclosed he is chair of the Extracorporeal Life Support Organization Registry; he received support for article research from the NIH; he disclosed off-label use of extracorporeal membrane oxygenation for more than 6 hours. Dr. Yalamuri received funding from Getinge. The remaining authors have disclosed that they do not have any potential conflicts of interest.

References

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    1. Guglin M, Zucker MJ, Bazan VM, et al.: Venoarterial ECMO for adults: JACC scientific expert panel. J Am Coll Cardiol. 2019; 73:698–716
    1. Henry TD, Tomey MI, Tamis-Holland JE, et al.; American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Cardiovascular and Stroke Nursing: Invasive management of acute myocardial infarction complicated by cardiogenic shock: A scientific statement from the American Heart Association. Circulation. 2021; 143:e815–e829
    1. Jentzer JC, Baran DA, Kyle Bohman J, et al.: Cardiogenic shock severity and mortality in patients receiving venoarterial extracorporeal membrane oxygenator support. Eur Heart J Acute Cardiovasc Care. 2022; 11:891–903
    1. Vallabhajosyula S, Prasad A, Bell MR, et al.: Extracorporeal membrane oxygenation use in acute myocardial infarction in the United States, 2000 to 2014. Circ Heart Fail. 2019; 12:e005929

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