Guiding complexity in V-A ECMO weaning decisions for cardiogenic shock: Insights from a conjoint analysis

Weaning and liberation from V-A ECMO for cardiogenic shock involves complex decision-making that requires balancing multiple clinical parameters. In the absence of specific weaning guidelines, ECMO centers rely on heterogeneous, institution-specific practices, which may adversely affect outcome. To gain insights into how professionals weigh multiple factors in complex weaning decisions, a survey was designed using conjoint analysis. The survey was presented to a large cohort of international ECMO clinicians via the EuroELSO network online between February 16, 2024 and May 1, 2024. Using conjoint analysis, a set of 14 hypothetical adult weaning scenarios, incorporating combinations of different attributes with varying levels across 4 cardiogenic shock etiologies was presented. Participants had to decide on liberation from ECMO (‘yes’ or ‘no’) based on a personal trade-off weighing all presented attributes for each scenario. In total, 316 participants from 49 different countries evaluated 4424 hypothetical scenarios. Pulse Pressure ≥30 mmHg (OR 2.56 (CI 2.03–3.24), cardiac index >2.1 L/min/m² (OR 2.5 (CI 1.87–3.43) and echocardiographically assessed left ventricular outflow velocity time integral (VTI) >15 cm (OR 2.53 (95% CI 201-3.2) all favored positive weaning decisions (all p < 0.001). Vasoactive-inotropic score (VIS; 11.1%), VTI (9.7%) and the presence of peripheral and/or pulmonary edema (9.8%) had the highest relative importance to overall weaning decisions. Echocardiography was found to contribute more to weaning decisions in ECMO novices. Weaning decisions were predominantly driven by parameters reflecting cardiac recovery. Leveraging these insights may set the stage for a clinical decision-support tool to benchmark individual practice against expert consensus.