C47-34 ECMO Bridging to Lung Transplant in the CAS Era

Introduction Extracorporeal membrane oxygenation (ECMO) is increasingly used as a bridge to lung transplant (BTT) for patients with end stage lung disease (ESLD) who are experiencing rapid deterioration while awaiting donor organs. This strategy is limited to a few centers and lacks robust practice guidelines. Prior studies list bridge to transplant (BTT) success rates ranging from 56% to 100% and one-year survival ranging from 75% to 100%. We report on our center’s experience with ECMO BTT. Methods We conducted a retrospective review of ESLD patients who were supported on ECMO as a BTT between July 1, 2024 to August 31, 2025 at the University of Pittsburgh Medical Center (UPMC). Results Twenty-one patients with ESLD were supported on ECMO between July 1, 2024 and August 31, 2025. Nine (43%) received lung transplant with an average CAS of 48.2 and twelve did not with an average CAS of 51.8. The two groups were comparable in terms of age, BMI, rate of mechanical ventilation, and severity of lung disease. The etiologies in the non-transplanted group included idiopathic pulmonary fibrosis (IPF) (5), scleroderma (1), severe combined immunodeficiency (1), tuberculosis (1), fibrotic hypersensitivity pneumonitis (1), MDA-5 dermatomyositis (1), silicosis ILD (1), and cystic fibrosis (1) while the transplanted cohorts diagnoses included diffuse parenchymal lung disease (3), IPF (3), pulmonary alveolar microlithiasis (1), dermatomyositis (1), and mixed connective tissue disease (1). Of the 9 transplanted patients, 7 were supported with VV ECMO, 1 with VA ECMO and 1 with VAV ECMO pre-transplant with an overall average duration of 232 hours. Of the 12 ECMO patients who were not transplanted, 8 were supported with VV ECMO, 2 with VA ECMO, and 2 with VAV ECMO with an overall average duration of 237 hours. Compared to those who were not transplanted, patients who received lung transplant had a lower CAS (p = 0.024), lower serum creatinine (p = 0.047), were ambulatory while on ECMO (p = 0.021), and were free of septic shock (p = 0.039) or stroke (p = 0.05). Conclusion ECMO as a BTT is a viable option in patients with ESLD who experience acute decompensation, as long as they have a single organ disease and remain ambulatory while on ECMO. Although ECMO configurations did not differ in our cohort prior studies have shown improved outcomes bridging with VV compared to VA/VAV. Going forward more research is needed to optimize patient selection and improve outcomes.