Associated Risks, Opportunities and Outcomes: Insights from a Long-Term High-Volume Center Using Extracorporeal Membrane Oxygenation as a Bridging Tool to Lung Transplantation

All articles of this category (opens in new window) Background: Extracorporeal membrane oxygenation (ECMO) as a bridging tool is a well-established treatment option for critically ill patients awaiting lung transplantation (LTx), though the risk of complications should not be underestimated. The current study analyzed a 13-year experience with ECMO-bridging among all transplant indications. Methods: All patients undergoing LTx between January 2012 and August 2025 were included. Outcomes were compared between ECMO-bridged and nonbridged patients. Median follow-up was 60 [IQR: 24–104] months. Results: Among the 1,492 patients transplanted during the study period, 100 patients (7%) required ECMO-bridging (venovenous ECMO, n = 67; veno-arterial ECMO, n = 33). Four venovenous ECMO patients (4%) were converted to veno-arterial ECMO during bridging time. The most frequent transplant indication among ECMO-bridged patients was idiopathic pulmonary fibrosis (28%), followed by cystic fibrosis (23%) and primary pulmonary hypertension (PPH, 22%). Eleven bridged patients (11%) underwent re-transplantation, of which 10 (91%) required venovenous ECMO. Across all transplant indications (bridged and nonbridged patients), PPH had the highest proportion of bridged patients (24%), followed by cystic fibrosis (10%). Median bridging time to LTx was 11 (7–26) days. Forty-two ECMO-bridged patients further required invasive mechanical ventilation. ECMO-bridging configuration was maintained in all patients during LTx. Excluding PPH patients, in whom postoperative prolonged ECMO is maintained by institutional protocol, ECMO-bridged patients required more often postoperative prolonged ECMO support (19% vs. 4%, p < 0.001). Overall, bridged patients showed a significantly higher incidence of primary graft dysfunction grade 3 72 hours posttransplant (18% vs. 3.9%, p < 0.001) as well as higher in-hospital mortality rates (12% vs. 3.4%, p < 0.001) compared to nonbridged patients. One-, 5-, and 8-year posttransplant outcomes showed reduced graft survival in bridged vs. nonbridged patients (81 vs. 92, 64 vs. 73, 55 vs. 61, p = 0.14) and reduced CLAD-free survival (88 vs. 98, 68 vs. 75, and 59 vs. 67%, p = 0.17), without any statistical significance, respectively. Conclusion: Although ECMO implantation is a life-saving bridging tool until a suitable organ offer is available, early mortality after LTx remains high among bridged patients. This study shows that further Lung Allocation Score optimization is necessary to reduce ECMO-bridging rates, particularly in PPH patients. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany