Predictors of extubation failure during ongoing VA-ECMO support after cardiac surgery.

BACKGROUND: As earlier extubation strategies expand during VA-ECMO support, data on predictors of extubation failure remain scarce. OBJECTIVES: We aimed to identify factors associated with extubation failure in cardiac surgery patients extubated during ongoing VA-ECMO support. METHODS: We conducted a retrospective single-center study including all adult patients extubated while receiving VA-ECMO between January 2016 and December 2020. The primary outcome was extubation failure, defined as unplanned reintubation within 7 days. Secondary outcomes included ventilator-free days, ICU and hospital length of stay, and mortality at 28 days and 1 year. RESULTS: A total of 186 patients were included. Median VA-ECMO duration was 9 days [6-14]. Extubation failure occurred in 44 patients (23.6%), mainly due to acute respiratory failure or neurological impairment. Extubation failure was associated with fewer ventilator-free days, longer ICU stay, and higher short- and long-term mortality. In multivariable analysis, older age (aOR 1.053, 95% CI 1.017-1.094; p = 0.006), renal replacement therapy during ICU stay (aOR 3.209, 95% CI 1.418-7.467; p = 0.006), and massive intraoperative transfusion (aOR 4.091, 95% CI 1.753-10.212; p = 0.002) were independently associated with extubation failure, whereas effective post-extubation cough was associated with success (aOR 0.116, 95% CI 0.033-0.368; p < 0.001). CONCLUSIONS: Extubation failure during ongoing VA-ECMO was frequent and associated with adverse outcomes. Markers of global vulnerability and airway protection may be more informative than conventional respiratory and hemodynamic parameters when assessing the risk of extubation failure in this population.