Dynamic Echocardiographic Trajectory Phenotypes During Veno-Arterial Extracorporeal Membrane Oxygenation and Their Association With In-Hospital Mortality: A Multicenter Cohort Study.

BACKGROUND: Current risk stratification for veno-arterial extracorporeal membrane oxygenation relies on static assessments, ignoring dynamic cardiac evolution. We aimed to identify longitudinal echocardiographic trajectory phenotypes and evaluate their association with in-hospital mortality. METHODS: We analyzed 2034 adults receiving veno-arterial extracorporeal membrane oxygenation for cardiogenic shock from a multicenter registry. Latent class mixed models and probabilistic template-matching were applied to serial echocardiographic data (left ventricular ejection fraction, end-diastolic diameter, right ventricular parameters) to identify trajectory phenotypes. Associations with mortality were evaluated using multivariable Cox and Fine-Gray competing risk models. RESULTS: Four dynamic phenotypes were identified: Dyn-A ("Refractory Stagnation," 17.0%), featuring persistent systolic suppression and progressive dilation; Dyn-B ("Isolated LV Recovery," 14.9%); Dyn-C ("Biventricular Failure," 6.1%); and Dyn-D ("Gradual Recovery," 61.9%). Static baseline phenotyping failed to stratify survival. Conversely, dynamic phenotypes were independently associated with mortality. The high-risk Dyn-A phenotype exhibited significantly higher mortality compared with the Dyn-B profile (adjusted hazard ratio 1.71, 95% CI 1.35-2.16), remaining significant after adjusting for baseline illness severity. CONCLUSIONS: Dynamic echocardiographic trajectories identify distinct phenotypes reflecting divergent cardiac responses to veno-arterial extracorporeal membrane oxygenation, ranging from recovery to progressive maladaptation. Longitudinal monitoring provides essential prognostic utility beyond static admission assessments.