Postcardiotomy cardiogenic shock (PCS) is a life-threatening complication after adult cardiac surgery that frequently necessitates venoarterial extracorporeal membrane oxygenation (VA-ECMO). Central and peripheral VA-ECMO cannulation strategies generate distinct hemodynamic and perfusion profiles; however, whether these differences translate into varying risks of acute brain injury (ABI) remains uncertain. We therefore compared ABI risk according to cannulation strategy in adults with PCS requiring VA-ECMO, with secondary objectives to determine the overall prevalence of ABI and characterize its major subtypes.

We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Scopus through April 15, 2025, for studies reporting ABI in adult PCS patients receiving VA-ECMO. ABI outcome was defined as ischemic stroke, intracranial hemorrhage, hypoxic-ischemic brain injury, seizures, unspecified stroke, and brain death. Random-effects meta-analysis was performed, incorporating a contemporary single-center cohort from Johns Hopkins Hospital (2020–2025).

The primary meta-analysis included seven cohorts (six published studies plus Johns Hopkins cohort; n = 2536), while secondary analyses included 17 cohorts (16 published studies plus Johns Hopkins cohort). Included patients (mean age = 65 years, BMI = 28 kg/m², 61% male) underwent central VA-ECMO cannulation in 32% and peripheral cannulation in 68%. The pooled risk of ABI did not differ by cannulation strategy (risk ratio [RR], 1.01; 95% CI, 0.85–1.21; I² = 0%), with similar ABI prevalence across groups (p = 0.99). Ischemic stroke and unspecified stroke were the most reported subtypes.

In adults with PCS supported by VA-ECMO, the risk of ABI was not significantly associated with cannulation strategy. These findings suggest that cannulation approach alone is unlikely to be the primary determinant of neurological risk in this population, underscoring the need for systematic neuroprotective strategies regardless of cannulation configuration.