Does sex affect outcomes in veno-arterial extracorporeal membrane oxygenation? a systematic review and meta-analysis

Extracorporeal membrane oxygenation (ECMO) is increasingly utilized for advanced cardiopulmonary support in critically ill patients, yet sex-based differences in outcomes remain inadequately characterized. This systematic review and meta-analysis compared mortality, complications, and resource utilization between male and female patients receiving veno-arterial ECMO (VA-ECMO). A systematic review and meta-analysis of studies comparing outcomes between male and female VA-ECMO patients was conducted. Pooled analyses were performed using random-effects models, with effect estimates reported as risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI). Statistical heterogeneity was assessed using the I² statistic. Eleven studies were included. No significant difference in overall mortality was observed between males and females (RR 0.99, 95% CI 0.93–1.06; p = 0.77; I² = 54%). ICU length of stay, ECMO duration, stroke rates, and RRT/dialysis were also comparable between sexes. Male patients exhibited a significantly lower risk of bleeding complications (RR 0.84, 95% CI 0.72–0.98; p = 0.03; I² = 46%), while limb ischemia was also less frequent in males (RR 0.55, 95% CI 0.45–0.68; p < 0.00001; I² = 0%). Subgroup analyses indicated lower mortality among matched male cohorts. Overall, mortality and most outcomes were similar between sexes in patients receiving VA-ECMO support, although lower risks of bleeding complications and limb ischemia were observed in males. Further prospective studies are needed to clarify sex-specific differences and optimize ECMO management strategies.