Donor stagnation and modification of lung allocation scores has resulted in a higher acuity of patient presentation prior to lung transplantation. Extracorporeal membrane oxygenation (ECMO) has been utilized as a bridge to lung transplant (BTT) although the effect of cannulation strategy on outcomes has not been well investigated. We sought to analyze contemporary data on ECMO BTT utilizing a large, international registry of patients.

Utilizing the Extracorporeal Life Support Organization registry, all adult patients from 2010-2022 undergoing ECMO as a bridge to lung transplantation (ECMO BTT) were identified. Patients were stratified by support type: venovenous or venoarterial.

A total of 1066 patients were identified. ECMO BTT increased over the study period (p<0.001) as did survival to hospital discharge (p<0.001) with overall survival of 87.7%. Venovenous patients experienced less complications on ECMO including dialysis (16.7% vs. 25.3%, p=0.006), stroke (1.4% vs. 5.1%, p=0.004), limb ischemia (0.2% vs. 3.4%, p<0.001) and required ECMO less frequently in the postoperative period (41.0%% vs. 53.4%, p=0.002) and for less time (4 days [2-7] vs. 5 days [3-9], p=0.01). In-hospital mortality was significantly lower for venovenous patients compared to venoarterial (11.0% vs. 18.5%, p=0.005). Increasing center volume of ECMO BTT was protective of in-hospital mortality (p<0.001) with benefit observed after around 45 total BTT intent cannulations.

ECMO BTT has resulted in improved post-transplant survival to discharge. Due to a higher rate of complications and worsened mortality, thoughtful implementation of venoarterial ECMO in BTT should be undertaken when assessing patient candidacy.