Impact of pre-transplant veno-venous extracorporeal membrane oxygenation on post-lung transplant infections

Bridging critically ill patients to lung transplantation with veno-venous extracorporeal membrane oxygenation (VV-ECMO) may increase infection risk, yet its impact on post-transplant outcomes remains unclear. We evaluated the incidence, timing, and risk factors for respiratory and bloodstream infections in patients supported with pre-operative VV-ECMO and assessed one-year survival. We conducted a retrospective cohort study of 293 adult lung transplant recipients at a single center between January 2018 and June 2023. Thirty-seven patients received pre-transplant VV-ECMO, and 256 did not. We compared the incidence and median time to first respiratory and bloodstream infections and estimated one-year survival. Cox proportional hazard models identified independent predictors of infection. VV-ECMO patients were younger (median 53.0 vs 63.0 years) and more often underwent bilateral transplantation for acute respiratory distress syndrome. Respiratory infections occurred in 64.9% of the VV-ECMO group versus 56.6% of controls (p = 0.38), with a shorter median time to first respiratory infection (8 vs 63 days). Bacterial bloodstream infections were more frequent after VV-ECMO (18.9% vs 6.3%, p = 0.016) and occurred earlier (99 vs 162 days). In multivariate analysis, VV-ECMO independently predicted bloodstream infection (HR 2.36, 95% CI 1.00-5.53; p = 0.049) but not a respiratory infection. One-year survival was equivalent (81.1% vs 89.8%; p = 0.16). Pre-transplant VV-ECMO is associated with earlier and increased bloodstream infections but does not compromise one-year survival, supporting its continued use as a bridge to lung transplantation.