Extracorporeal membrane oxygenation (ECMO) may be used to support critically ill patients before lung transplantation. The relationship between preoperative venoarterial and venovenous ECMO and their relationship with lung transplantation indications remain poorly elucidated.

This study analyzed data from the Organ Procurement and Transplantation Network database pertaining to adult lung transplant recipients who underwent transplantation procedures between January 1, 2018, and December 20, 2023. Patients were categorized by preoperative ECMO status. Multivariable risk adjustment was performed with Cox mixed-effect models and logistic regression. Subgroup analysis was performed on patients who underwent lung transplantation for coronavirus disease 2019 (COVID-19) and restrictive lung disease.

Of 12,098 lung transplant recipients, 854 (7%) required ECMO preoperatively. Patients who underwent preoperative ECMO were younger (median age, 52 years vs 63 years; P < .001), were more likely not to have diabetes (81.0% vs 74.5%; P < .001) and had different primary diagnoses compared with other lung transplant recipients. After risk adjustment, preoperative venovenous ECMO use was not associated with a shorter time to graft failure or lower survival (P = .864 and P = .140, respectively). However, preoperative venoarterial ECMO was associated with lower survival (hazard ratio [HR], 1.36; P = .014) and higher need for ECMO 72 hours after transplantation (odds ratio, 3.83; P < .001). In subgroup analysis, patients with restrictive lung disease who required venoarterial ECMO before lung transplantation had inferior survival compared to those with VV-ECMO and no ECMO (P = .010 and P = .023, respectively). Patients who underwent lung transplantation for COVID-19 had similar survival regardless of their preoperative venovenous ECMO status (HR, 0.943; P = .522).

Preoperative venoarterial ECMO is associated with worse overall survival in lung transplant recipients, but venovenous ECMO is not. These findings are consistent across disease origin and transplantation indication.