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Bedside EVLWI is commonly assessed using single-indicator transpulmonary thermodilution (TPTD), which is increasingly employed to guide fluid therapy. However, TPTD-derived EVLWI values can be significantly affected by extracorporeal blood flow (ECBF), leading to inaccurate estimates during ECMO. In contrast, artificial intelligence (AI)-based automated lung segmentation of chest computed tomography (CT) enables reliable ECBF-independent visualization and quantification of pulmonary edema (EVLWI\n                      <jats:sub>CT<\/jats:sub>\n                      ). The primary objective was to compare EVLWI measured by TPTD (EVLWI\n                      <jats:sub>TPTD<\/jats:sub>\n                      ) with EVLWI\n                      <jats:sub>CT<\/jats:sub>\n                      in ARDS patients on VV ECMO. The secondary objective was to derive and validate an ECBF-dependent correction factor to improve the accuracy of EVLWI\n                      <jats:sub>TPTD<\/jats:sub>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      In this retrospective, single-center observational cohort study of 64 patients with severe ARDS on VV ECMO, routine chest CT images and concurrent TPTD measurements, performed immediately before or after the CT scan, were analyzed. EVLWI was quantified using AI-based automated CT segmentation (EVLWI\n                      <jats:sub>CT<\/jats:sub>\n                      ) and TPTD (EVLWI\n                      <jats:sub>TPTD<\/jats:sub>\n                      ), the latter performed immediately before or after the CT scan. A multiple regression model using EVLWI\n                      <jats:sub>CT<\/jats:sub>\n                      as the reference was applied to derive an ECBF-dependent correction factor for EVLWI\n                      <jats:sub>TPTD<\/jats:sub>\n                      (EVLWI\n                      <jats:sub>TPTDcorr<\/jats:sub>\n                      ).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      EVLWI\n                      <jats:sub>TPTD<\/jats:sub>\n                      significantly overestimated pulmonary edema compared to EVLWI\n                      <jats:sub>CT<\/jats:sub>\n                      (24.3 [15.8\u201330.0] vs. 10.2 [5.8\u201314.8] ml\/kg;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001), with a mean bias of \u2212\u200912.3\u00a0ml\/kg and limits of agreement from \u2212\u200930.9 to 6.2\u00a0ml\/kg. A correction factor of 3.439\u00a0ml\/kg per liter of ECBF was identified. After adjustment, EVLWI\n                      <jats:sub>TPTDcorr<\/jats:sub>\n                      did not differ significantly from EVLWI\n                      <jats:sub>CT<\/jats:sub>\n                      (8.7 [4.2\u201315.8] vs. 10.2 [5.8\u201314.8] ml\/kg;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.393), with a reduced bias of 0.96\u00a0ml\/kg and narrower limits of agreement (\u201316.4 to 18.4\u00a0ml\/kg).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In severe ARDS patients on VV ECMO, EVLWI obtained via TPTD was significantly overestimated due to ECBF interference. TPTD systematically overestimates EVLWI due to ECBF interference. Incorporating an ECBF-adjusted correction factor markedly improves agreement with AI-based CT quantification, enhancing the reliability and clinical applicability of TPTD-derived EVLWI for fluid management in this high-risk population.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration<\/jats:title>\n                    <jats:p>\n                      German Clinical Trials Register (DRKS00026246). Registered 14\/09\/2021.\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"https:\/\/drks.de\/search\/en\/trial\/DRKS00026246\" ext-link-type=\"uri\">https:\/\/drks.de\/search\/en\/trial\/DRKS00026246<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12890-026-04260-9","type":"journal-article","created":{"date-parts":[[2026,4,7]],"date-time":"2026-04-07T00:36:14Z","timestamp":1775522174000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Comparative assessment of extravascular lung water index in ARDS patients on veno-venous ECMO: transpulmonary thermodilution versus AI-driven chest CT segmentation"],"prefix":"10.1186","volume":"26","author":[{"given":"Matthias","family":"Otto","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Mohr","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julia","family":"Zimmermann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nils","family":"Rathmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christoph","family":"Boesing","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manfred","family":"Thiel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joerg","family":"Krebs","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Luecke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patricia R.M.","family":"Rocco","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alice Marguerite","family":"Conrad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,4,7]]},"reference":[{"issue":"10358","key":"4260_CR1","doi-asserted-by":"publisher","first-page":"1145","DOI":"10.1016\/S0140-6736(22)01485-4","volume":"400","author":"LDJ Bos","year":"2022","unstructured":"Bos LDJ, Ware LB. 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J Crit Care. 2016;33:106\u201313.","journal-title":"J Crit Care"}],"container-title":["BMC Pulmonary Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12890-026-04260-9","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12890-026-04260-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12890-026-04260-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T21:33:31Z","timestamp":1781645611000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12890-026-04260-9"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,7]]},"references-count":45,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["4260"],"URL":"https:\/\/doi.org\/10.1186\/s12890-026-04260-9","relation":{},"ISSN":["1471-2466"],"issn-type":[{"value":"1471-2466","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,7]]},"assertion":[{"value":"26 August 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"25 March 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"7 April 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This retrospective, observational, single-center, cohort study was approved by the local ethics committee (Medizinische Ethikkommission II, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, registration number 2021\u2009\u2212\u2009831). The present study was conducted in the 25-bed intensive care unit (ICU) of the Department of Anesthesiology and Critical Care Medicine at the University Hospital Mannheim, and it was conducted in accordance with the Declaration of Helsinki. Due to the retrospective observational study design, the Institutional Review Board (IRB) waived the requirement for informed consent from all participants. Prior to the initiation of the data analysis, the study was prospectively registered with the German Clinical Trials Register (DRKS00026246).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"174"}}