Development and Internal Validation of an Early Multiorgan Injury Model for 90-Day Mortality in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock Treated With Veno-Arterial Extracorporeal Membrane Oxygenation

Development and Internal Validation of an Early Multiorgan Injury Model for 90-Day Mortality in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock Treated With Veno-Arterial Extracorporeal Membrane Oxygenation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and Internal Validation of an Early Multiorgan Injury Model for 90-Day Mortality in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock Treated With Veno-Arterial Extracorporeal Membrane Oxygenation Ruike Ma, Xiaoxiao Zhou, Changqing Cai, Yifeng Du, Wei Zhang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9311301/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains associated with high mortality despite advances in revascularization, intensive care, and temporary mechanical circulatory support. In patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO), early prognosis is likely determined not by a single biomarker but by the integrated burden of myocardial dysfunction, end-organ injury, reperfusion status, and oxygenation failure. We aimed to develop and internally validate a pragmatic early risk-stratification model for 90-day mortality using multiorgan injury variables available around the time of VA-ECMO initiation. Methods: This single-centre retrospective cohort study consecutively enrolled adult patients with AMI-CS who received VA-ECMO at Linyi People’s Hospital between January 2021 and December 2025. Patients who underwent extracorporeal cardiopulmonary resuscitation were excluded. The primary endpoint was 90-day all-cause mortality; 28-day and 365-day all-cause mortality were secondary endpoints. Baseline characteristics, reperfusion-related variables, and peri-ECMO organ-injury markers were compared between 90-day survivors and non-survivors. Candidate predictors were first screened in univariable logistic regression and then entered into multivariable analysis according to clinical relevance, biological plausibility, model parsimony, event number constraints, and inter-variable overlap. Model performance was evaluated using receiver operating characteristic analysis, calibration assessment, and internal validation with 1,000 bootstrap resamples. Kaplan-Meier analysis was performed after empirical risk stratification based on model-derived predicted probabilities. Results: A total of 142 patients were included. The median age was 57.5 years (interquartile range [IQR], 50.0- 67.0), and 112 patients (78.9%) were men. Mortality at 28, 90, and 365 days was 33.8% (48/142), 40.8% (58/142), and 41.5% (59/142), respectively. Compared with 90-day survivors, non-survivors had lower left ventricular ejection fraction (LVEF), higher lactate, lower oxygenation index, a higher frequency of post-procedural TIMI flow grade <3, and higher levels of aspartate aminotransferase, blood urea nitrogen, creatinine, and NT-proBNP. In multivariable analysis, higher LVEF was independently associated with lower 90-day mortality (OR per 5% increase, 0.636; 95% CI, 0.489-0.827; P<0.001), whereas higher creatinine (OR per 10 μmol/L increase, 1.101; 95% CI, 1.036-1.170; P=0.002), post-procedural TIMI flow grade <3 (OR, 3.664; 95% CI, 1.159-11.587; P=0.027), and lower oxygenation index (OR per 10-unit increase, 0.944; 95% CI, 0.898-0.992; P=0.022) were independently associated with increased mortality. The apparent area under the curve was 0.841, with an optimism-corrected area under the curve of 0.821 after bootstrap validation. The low-, intermediate-, and high-risk groups had 90-day mortality rates of 8.5%, 35.4%, and 78.7%, respectively (log-rank P<0.001). Conclusions: In patients with AMI-CS treated with VA-ECMO, early impairment in cardiac function, renal function, reperfusion quality, and oxygenation was independently associated with 90-day mortality. A prediction model incorporating LVEF, creatinine, post-procedural TIMI flow grade, and oxygenation index showed good discrimination and internal validity. This model may provide a practical framework for early risk assessment after VA-ECMO initiation, although external validation is required before routine clinical implementation. acute myocardial infarction cardiogenic shock extracorporeal membrane oxygenation mortality risk stratification multiorgan injury Full Text Additional Declarations No competing interests reported. Supplementary Files PeerReviewOnly.zip Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 01 May, 2026 Editor invited by journal 10 Apr, 2026 Editor assigned by journal 08 Apr, 2026 Submission checks completed at journal 08 Apr, 2026 First submitted to journal 03 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9311301","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":635687781,"identity":"1de872c4-f9f5-478f-a6ef-014d3b1b9452","order_by":0,"name":"Ruike Ma","email":"","orcid":"","institution":"Linyi People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ruike","middleName":"","lastName":"Ma","suffix":""},{"id":635687782,"identity":"c5475064-a043-4e0c-8c21-56da9e7d5ccd","order_by":1,"name":"Xiaoxiao Zhou","email":"","orcid":"","institution":"Linyi Cancer 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Oxygenation\u003c/p\u003e","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"acute myocardial infarction, cardiogenic shock, extracorporeal membrane oxygenation, mortality, risk stratification, multiorgan injury","lastPublishedDoi":"10.21203/rs.3.rs-9311301/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9311301/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains \u0026nbsp;associated with high mortality despite advances in revascularization, intensive care, and temporary \u0026nbsp;mechanical circulatory support. In patients treated with veno-arterial extracorporeal membrane \u0026nbsp;oxygenation (VA-ECMO), early prognosis is likely determined not by a single biomarker but by the \u0026nbsp;integrated burden of myocardial dysfunction, end-organ injury, reperfusion status, and oxygenation \u0026nbsp;failure. We aimed to develop and internally validate a pragmatic early risk-stratification model for 90-day \u0026nbsp;mortality using multiorgan injury variables available around the time of VA-ECMO initiation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: This single-centre retrospective cohort study consecutively enrolled adult patients with AMI-CS who \u0026nbsp;received VA-ECMO at Linyi People’s Hospital between January 2021 and December 2025. Patients who \u0026nbsp;underwent extracorporeal cardiopulmonary resuscitation were excluded. The primary endpoint was \u0026nbsp;90-day all-cause mortality; 28-day and 365-day all-cause mortality were secondary endpoints. Baseline \u0026nbsp;characteristics, reperfusion-related variables, and peri-ECMO organ-injury markers were compared between 90-day \u0026nbsp;survivors and non-survivors. Candidate predictors were first screened in univariable logistic regression and then \u0026nbsp;entered into multivariable analysis according to clinical relevance, biological plausibility, model parsimony, event number constraints, and inter-variable overlap. Model performance was evaluated using receiver operating \u0026nbsp;characteristic analysis, calibration assessment, and internal validation with 1,000 bootstrap resamples. Kaplan-Meier \u0026nbsp;analysis was performed after empirical risk stratification based on model-derived predicted probabilities. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: A total of 142 patients were included. The median age was 57.5 years (interquartile range [IQR], 50.0- \u0026nbsp;67.0), and 112 patients (78.9%) were men. Mortality at 28, 90, and 365 days was 33.8% (48/142), 40.8% (58/142), \u0026nbsp;and 41.5% (59/142), respectively. Compared with 90-day survivors, non-survivors had lower left ventricular \u0026nbsp;ejection fraction (LVEF), higher lactate, lower oxygenation index, a higher frequency of post-procedural TIMI flow \u0026nbsp;grade \u0026lt;3, and higher levels of aspartate aminotransferase, blood urea nitrogen, creatinine, and NT-proBNP. In \u0026nbsp;multivariable analysis, higher LVEF was independently associated with lower 90-day mortality (OR per 5% \u0026nbsp;increase, 0.636; 95% CI, 0.489-0.827; P\u0026lt;0.001), whereas higher creatinine (OR per 10 μmol/L increase, 1.101; 95% \u0026nbsp;CI, 1.036-1.170; P=0.002), post-procedural TIMI flow grade \u0026lt;3 (OR, 3.664; 95% CI, 1.159-11.587; P=0.027), and \u0026nbsp;lower oxygenation index (OR per 10-unit increase, 0.944; 95% CI, 0.898-0.992; P=0.022) were independently \u0026nbsp;\u0026nbsp;associated with increased mortality. The apparent area under the curve was 0.841, with an optimism-corrected area \u0026nbsp;under the curve of 0.821 after bootstrap validation. The low-, intermediate-, and high-risk groups had 90-day \u0026nbsp;mortality rates of 8.5%, 35.4%, and 78.7%, respectively (log-rank P\u0026lt;0.001). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusions: In patients with AMI-CS treated with VA-ECMO, early impairment in cardiac function, renal \u0026nbsp;function, reperfusion quality, and oxygenation was independently associated with 90-day mortality. A prediction \u0026nbsp;model incorporating LVEF, creatinine, post-procedural TIMI flow grade, and oxygenation index showed good \u0026nbsp;discrimination and internal validity. This model may provide a practical framework for early risk assessment after \u0026nbsp;VA-ECMO initiation, although external validation is required before routine clinical implementation.\u003c/p\u003e","manuscriptTitle":"Development and Internal Validation of an Early Multiorgan Injury Model for 90-Day Mortality in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock Treated With Veno-Arterial Extracorporeal Membrane Oxygenation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 17:23:33","doi":"10.21203/rs.3.rs-9311301/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-05-01T15:01:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-10T19:22:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-09T02:51:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-09T02:51:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2026-04-03T09:15:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1b8b27d5-d531-409e-adfd-bc0ee5ff90fe","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewersInvited","content":"56","date":"2026-05-01T15:01:51+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T17:23:33+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 17:23:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9311301","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9311301","identity":"rs-9311301","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}