Background: A body mass index (BMI) ≥ 35 kg/m² is traditionally a contraindication to extracorporeal support. We evaluated outcomes and quality of life (QoL) associated with veno-venous extracorporeal membrane oxygenation (VV-ECMO) in patients with BMI ≥ 35 kg/m².

Methods: A multi-institution retrospective analysis was conducted on patients requiring VV-ECMO from May 2020 to December 2021. Patients were ≥ 18 years and met clinical criteria for extracorporeal support. Data on survival, discharge, decannulation, tracheostomy, and extubation times were collected. Statistical analysis included t-tests, chi-square tests, Kaplan-Meier survival plots, time-to-event models, and multiple linear regressions. Cox proportional hazards models adjusted for confounders. The Short-Form Health Survey (SF-12) assessed physical and mental scores. Relationships between QoL and outcomes were evaluated using generalized linear and mixed models.

Results: Among 181 patients, 80 had a BMI ≥ 35 kg/m². Median age was 43.5 years, with 59.7% male and 97.2% white. Patients with a BMI ≥ 35 kg/m² had a shorter time to discharge (HR: 1.97, 95% CI: 1.16-3.36, p = 0.013) and lower likelihood of death post-discharge (HR: 0.169, 95% CI: 0.036-0.799, p = 0.025). Higher BMI patients had higher survival rates at discharge (78.8% vs. 63.4%, p = 0.037). Decannulation and extubation times were similar between cohorts. SF-12 scores demonstrated no significant difference in physical or mental capacity (p=0.822, 0.582).

Conclusions: Patients with BMI ≥ 35 kg/m² do not have worse ECMO outcomes and show similar QoL metrics. These findings challenge BMI ≥ 35 kg/m² as an ECMO contraindication. Further prospective studies are needed.