The use of extracorporeal membrane oxygenation (ECMO) has expanded and is now widely applied to perioperative care in lung transplant. Respiratory failure after lung transplant is a clinical challenge where ECMO plays a critical role.

The Extracorporeal Life Support Organization registry was queried for patients 18 years and older who were treated with ECMO after lung transplant in 2010–2022. ECMO runs for more than 24 hours after lung transplant were included regardless of the timing of initiation. Univariable analyses were performed to compare procedural and patient characteristics across ECMO eras. Multivariable logistic regression was performed to identify predictors of surviving to discharge.

One-thousand nine-hundred and sixty-six patients met the inclusion criteria, and 1422 patients (72.3%) survived to discharge. The number of ECMO runs steadily increased throughout the study period, with a trend of improving survival. Higher annual center volume (Odds Ratio[OR]: 0.97, p < 0.001), longer ECMO duration (OR 1.01/day, p < 0.001), veno-arterial mode (OR 2.28, p < 0.001), initiation of ECMO >72 hours after transplant (OR 3.93, p < 0.001), and ventilator duration >5 days (1.55, p = 0.035) were associated with higher probability of survival to discharge.

ECMO after lung transplant has expanded over the last 12 years along with improved survival. The data suggest a potential benefit of early ECMO initiation in this patient population. High ECMO volume was associated with better outcomes, and expertise in ECMO is considered essential in lung transplant centers.