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Peer-reviewedCC BY 4.0Critical Care Medicine

Time-Dependent Effects of Inotropic Exposure During Venoarterial Extracorporeal Membrane Oxygenation Support on the Probability of Extracorporeal Membrane Oxygenation Weaning Failure

  • Myrthe P.J. van Steenwijk1,2
  • Lara C.A. Pladet1,3
  • Atreyu van Esch1
  • Hong Jun Shi1
  • Dirk W. Donker3,4
  • Yannick Taverne5
  • Jeroen J.H. Bunge1,2
  • Carlos V. Elzo Kraemer6
  • Jacinta J. Maas6
  • Leon J. Montenij7
  • Luuk C. Otterspoor7
  • Erik Scholten8
8 more authors
  • Laurien van Koppenhagen9
  • Joost van Rosmalen10
  • Diederik Gommers1
  • Alina A. Constantinescu2
  • Rudolf A. de Boer2
  • Jacob E. Møller11
  • Dimitris Rizopoulos12
  • Christiaan L. Meuwese1,2
12 affiliations
  1. 1Department of Intensive Care Adults, Erasmus Medical Center, Rotterdam, The Netherlands.
  2. 2Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus Medical Center, Rotterdam, The Netherlands.
  3. 3Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands.
  4. 4Department of Cardiovascular and Respiratory Physiology, University of Twente, Enschede, The Netherlands.
  5. 5Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.
  6. 6Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.
  7. 7Department of Intensive Care, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.
  8. 8Department of Intensive Care, Sint Antonius Hospital, Nieuwegein, The Netherlands.
  9. 9Department of Intensive Care, Isala, Zwolle, The Netherlands.
  10. 10Department of Epidemiology & Health Economics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
  11. 11Department of Cardiology, Copenhagen University Hospital–Rigshospitalet, Denmark.
  12. 12Departments of Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands.
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Abstract

OBJECTIVES:: During venoarterial extracorporeal membrane oxygenation (VA ECMO), organ perfusion no longer entirely depends on native cardiac output, which may reduce the therapeutic advantage of inotropic drugs relative to their risks. We hypothesized that, in this setting, higher cumulative inotropic exposure would be associated with impaired cardiac recovery.

DESIGN:: Observational cohort study on the effects of longitudinal inotropic exposure during VA ECMO support. Temporal changes in inotropic support during VA ECMO support were evaluated. Cumulative inotropic exposure per day during VA ECMO support was calculated using the area under the curve of a standardized inotropic score. These cumulative inotropic scores were associated with the risk of ECMO weaning failure up to 30 days (a composite of death, ongoing need for ECMO support, or the need for heart replacement therapy), mortality, and complications, using joint modeling techniques.

SETTING:: Six hospitals in the Netherlands.

PATIENTS:: Adult patients with severe cardiogenic shock (CS) receiving VA ECMO support between 2018 and 2024.

INTERVENTIONS:: None.

MEASUREMENTS AND MAIN RESULTS:: Out of 440 patients with various causes of CS, 235 patients (53.4%) developed ECMO weaning failure. Inotropic support remained largely unchanged in the days following VA ECMO initiation. Adjusted joint models showed that a higher cumulative inotropic exposure during VA ECMO support was associated with an increased risk for ECMO weaning failure (hazard ratio [HR], 1.04; 95% CI, 1.00–1.07), 30-day mortality (HR, 1.04; 95% CI, 1.01–1.08), arrhythmias (HR, 1.05; 95% CI, 1.01–1.08), and protracted lactate clearance (HR, 0.96; 95% CI, 0.92–0.99).

CONCLUSIONS:: In patients requiring VA ECMO support for refractory CS, inotropic support is often maintained at similar levels after ECMO initiation. Higher cumulative inotropic exposure was associated with an increased risk for ECMO weaning failure. Prospective studies are needed to investigate whether inotropes can be tapered or even stopped and whether such a strategy could improve cardiac recovery.

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Cite

BibTeXRIS
BibTeX
@article{steenwijk2026timedependent,
  title = {{Time-Dependent Effects of Inotropic Exposure During Venoarterial Extracorporeal Membrane Oxygenation Support on the Probability of Extracorporeal Membrane Oxygenation Weaning Failure}},
  author = {Myrthe P.J. van Steenwijk and Lara C.A. Pladet and Atreyu van Esch and Hong Jun Shi and Dirk W. Donker and Yannick Taverne and Jeroen J.H. Bunge and Carlos V. Elzo Kraemer and Jacinta J. Maas and Leon J. Montenij and Luuk C. Otterspoor and Erik Scholten and Laurien van Koppenhagen and Joost van Rosmalen and Diederik Gommers and Alina A. Constantinescu and Rudolf A. de Boer and Jacob E. Møller and Dimitris Rizopoulos and Christiaan L. Meuwese},
  journal = {Critical Care Medicine},
  year = {2026},
  month = sep,
  doi = {10.1097/ccm.0000000000007338},
  url = {https://doi.org/10.1097/ccm.0000000000007338},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Time-Dependent Effects of Inotropic Exposure During Venoarterial Extracorporeal Membrane Oxygenation Support on the Probability of Extracorporeal Membrane Oxygenation Weaning Failure
AU  - Myrthe P.J. van Steenwijk
AU  - Lara C.A. Pladet
AU  - Atreyu van Esch
AU  - Hong Jun Shi
AU  - Dirk W. Donker
AU  - Yannick Taverne
AU  - Jeroen J.H. Bunge
AU  - Carlos V. Elzo Kraemer
AU  - Jacinta J. Maas
AU  - Leon J. Montenij
AU  - Luuk C. Otterspoor
AU  - Erik Scholten
AU  - Laurien van Koppenhagen
AU  - Joost van Rosmalen
AU  - Diederik Gommers
AU  - Alina A. Constantinescu
AU  - Rudolf A. de Boer
AU  - Jacob E. Møller
AU  - Dimitris Rizopoulos
AU  - Christiaan L. Meuwese
PY  - 2026
DA  - 2026/09/25
JO  - Critical Care Medicine
DO  - 10.1097/ccm.0000000000007338
UR  - https://doi.org/10.1097/ccm.0000000000007338
AB  - OBJECTIVES:: During venoarterial extracorporeal membrane oxygenation (VA ECMO), organ perfusion no longer entirely depends on native cardiac output, which may reduce the therapeutic advantage of inotropic drugs relative to their risks. We hypothesized that, in this setting, higher cumulative inotropic exposure would be associated with impaired cardiac recovery.  DESIGN:: Observational cohort study on the effects of longitudinal inotropic exposure during VA ECMO support. Temporal changes in inotropic support during VA ECMO support were evaluated. Cumulative inotropic exposure per day during VA ECMO support was calculated using the area under the curve of a standardized inotropic score. These cumulative inotropic scores were associated with the risk of ECMO weaning failure up to 30 days (a composite of death, ongoing need for ECMO support, or the need for heart replacement therapy), mortality, and complications, using joint modeling techniques.  SETTING:: Six hospitals in the Netherlands.  PATIENTS:: Adult patients with severe cardiogenic shock (CS) receiving VA ECMO support between 2018 and 2024.  INTERVENTIONS:: None.  MEASUREMENTS AND MAIN RESULTS:: Out of 440 patients with various causes of CS, 235 patients (53.4%) developed ECMO weaning failure. Inotropic support remained largely unchanged in the days following VA ECMO initiation. Adjusted joint models showed that a higher cumulative inotropic exposure during VA ECMO support was associated with an increased risk for ECMO weaning failure (hazard ratio [HR], 1.04; 95% CI, 1.00–1.07), 30-day mortality (HR, 1.04; 95% CI, 1.01–1.08), arrhythmias (HR, 1.05; 95% CI, 1.01–1.08), and protracted lactate clearance (HR, 0.96; 95% CI, 0.92–0.99).  CONCLUSIONS:: In patients requiring VA ECMO support for refractory CS, inotropic support is often maintained at similar levels after ECMO initiation. Higher cumulative inotropic exposure was associated with an increased risk for ECMO weaning failure. Prospective studies are needed to investigate whether inotropes can be tapered or even stopped and whether such a strategy could improve cardiac recovery.
SN  - 0090-3493
SN  - 1530-0293
ER  -