This retrospective single-center study compared higher versus lower initial flow-index in 553 patients receiving V-A ECMO between 2014 and 2024. After excluding cerebral death, multi-organ failure occurred in 32.7% of the high-flow group versus 23.0% of the low-flow group. Initial flow-index remained associated with multi-organ failure after adjustment (OR 1.102 per 0.1 L/min/m2, 95% CI 1.001–1.214). High-flow patients had greater baseline haemodynamic compromise, and exploratory mediation analysis suggested an indirect association through early hemolysis. Higher flow-index was also associated with worse neurological outcome and reduced survival.
Higher initial ECMO flow-index was associated with organ failure and poorer outcomes, but these findings do not establish that higher flow causes harm or that reducing flow improves outcomes.
Study limitation: Retrospective single-center data and greater shock severity in high-flow patients limit causal interpretation; mediation findings remain exploratory.
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