The establishment of VERGE, the first national VA ECMO registry in Germany provides a unique perspective on the implementation and outcomes of this life-sustaining technology. This first report highlights several important aspects of routine VA ECMO support.

Primary endpoint of this report was hospital survival—which varied significantly with the indication for ECMO. While survival was 58% in shock and 28% in ECRP. These are well in the range of the ELSO-report, stating 46% and 31%, respectively [8]. Data of randomized trials in VA ECMO in acute myocardial infarction associated shock show a similar 30-day survival of 52% [9]. Randomized data on ECPR had a comparable survival in the ECPR arm (32% CPC1-2 180-day survival [10] and 20% CPC 1–2 30-day survival [11]. These survival rated, however, cannot be directly compared as only CPC 1–2 survival was measured, follow-up was longer and not all patients revived an ECPR in this arm. In VERGE, CPC 1–2 at discharge was 23%. The poor survival rate of the peri-procedural group is alarming. As the number of patients in this subgroup is still extremely low, no further conclusions can be drawn. Other studies to peri-procedural ECMO show better results [12, 13].

Compared to randomized studies, a relatively high proportion of LV venting (23%) was observed. For instance, patients included in the ECLS-SHOCK study were treated with a venting device in 5.8% of the cases [9]. In the first year of the registry's existence, it is too early to draw conclusions from this observation.

The length of intensive care unit (ICU) stay differed significantly between survivors and non-survivors. For patients in cardiogenic shock, the ICU stay was 20 days versus 9 days (p < 0.001), and for the cohort of eCPR patients, it was 20 days versus 2 days (p < 0.001). Given the resource-intensive nature of these therapies, the duration of such treatments must be carefully considered before initiating an ECMO program.

The median age at cannulation was 61 years for patients undergoing VA ECMO for shock and 60 years for ECPR, underscoring a trend toward the higher utilization in older patients. This reflects a broader shift within the age spectrum and supports the well-documented correlation between increased age and reduced survival likelihood [14, 15]. Our findings corroborate the relationship between survival rates and age, yet they do not pinpoint a clear cutoff age that significantly alters outcomes, moreover, in our data correlation was weak. This absence of a definitive age threshold poses critical questions about the other potential factors influencing outcomes, which might be deduced from this comprehensive dataset. The fact that patients over the age of 80 are being treated with ECPR epitomizes the challenges faced by medical teams. These challenges are not solely clinical but encompass the timely and effective use of VA ECMO before complete patient information is available.

The lactate levels in surviving shock patients had a median of 5.3 mmol/L, similar to those of the patients enrolled in the ECLS Shock trial [9], while non-survivors exhibited significantly higher levels. A correlation of prognosis and lactate has been shown earlier [16]. Similarly, in ECPR patients, lactate levels were significantly different between survivors and non-survivors. Logistic regression analysis demonstrated a substantial influence of lactate levels on survival probability. It is not known how many centers are capable of measuring lactate levels above 20 or 25 mmol/L. This may have affected the categorization into lactate groups. However, in VERGE, no patient with a lactate above 25 mmol/L survived, which might be a cornerstone for Indication for VA ECMO.

Further conclusions may be drawn from aggregated data in subsequent years. Moreover, the pH was a strong predictor of survival in both ECPR as well as shock. Importantly, pH itself is an aggregate of respiratory and metabolic acid–base disturbances and, therefore, linked to lactate. With data shown here, we cannot differentiate between respiratory or metabolic acidosis. In VERGE, no patient with a pH below 6.7 survived and prognosis was best in patients with an alkalosis. These registry data, however, cannot be used to justify a hyperventilation strategy of VA ECMO patients and further research is needed.

The reported data are subject to a reporting bias. The 14 contributing centers all have a high level of ECMO activity and a stronger inclination toward scientific research, meaning that the report does not yet reflect the true state of patient care across Germany. With the annual publication of the registry, the number of participating centers is expected to increase. The aim of this registry is to provide a comprehensive description of the VA ECMO landscape in Germany. A concise data structure is essential to ensure high adherence to the registry, which may result in some imprecise definitions. For instance, unlike in prospective randomized studies, the definition of cardiogenic shock was left to the discretion of the participating centers.