Mortality after Lung Transplantation for Children Bridged with Extracorporeal Membrane Oxygenation

Rationale: Extracorporeal membrane oxygenation (ECMO) is increasingly used to bridge children who are wait-listed and failing conventional respiratory support for lung transplantation. Objectives: To compare in-hospital mortality and a composite outcome of 1-year mortality or retransplantation in children bridged with ECMO, supported with mechanical ventilation (MV), and given neither support. Methods: The United Network for Organ Sharing was used to analyze lung transplant recipients aged <= 20 years from January 2004 to August 2019. Recipients were categorized according to their degree of respiratory support at the time of transplant, including ECMO, MV, or neither. Multivariable analysis was used to evaluate support type and in-hospital mortality. Results: Of 1,014 children undergoing a lung transplant, 68 (6.7%) required ECMO as a bridge to transplant, 144 (14.2%) required MV, and 802 (79.1%) required neither. Primary diagnosis in the ECMO cohort included cystic fibrosis (43%), pneumonia and/or acute respiratory distress syndrome (10.3%), interstitial pulmonary fibrosis (7.4%), and pulmonary hypertension (5.9%). The number of patients bridged with ECMO increased throughout the study period from 0% in 2004 to 16.7% in 2018. Multivariable analysis showed bridging with both ECMO (adjusted odds ratio, 3.57; 95% confidence interval, 1.42-8.97) and MV (adjusted odds ratio, 2.67; 95% confidence interval, L26-5.57) increased in-hospital mortality after lung transplantation. However, there was no difference in composite outcome of mortality and retransplantation at 1 year between the three groups. Conclusions: ECMO to bridge children receiving lung transplantation has increased. Despite this, ECMO is a high-risk bridge strategy for children awaiting lung transplantation. Future research should target interventions that can be focused on improving survival in these patients.