Extracorporeal Membrane Oxygenation Versus Off-pump Technique in Lung Transplantation: A Meta-analysis With Reconstructed Time-to-event Data.
Passos, F. S., et al.Transplantation. 2026 Feb 1;110(2):e472-e480.
Aims
This study aimed to compare two intraoperative strategies, extracorporeal membrane oxygenation (ECMO) versus off-pump, in lung transplantation.
Interventions
Three electronic databases were searched for relavant literature: PubMed, EMBASE and Cochrane Library. Screening of titles and abstracts followed by data extraction were performed by two indepedent reviewers. The Cochrane Collaboration tool for assessing the risk of bias in nonrandomized studies (ROBINS-I) was used to assess the methodological quality of the included studies.
Participants
6 studies were included in the review.
Outcomes
Primary outcome: overall survival. Secondary outcomes: time until extubation, intensive care unit (ICU) length of stay (LOS), hospital LOS, primary graft dysfunction (PGD), and requirement for renal replacement therapy.
Follow-up
N/A
CET Conclusions
The use of extracorporeal membrane oxygenation (ECMO) during lung transplantation (LT) has traditionally only been utilised when needed in cases with intraoperative complication. Increasingly, major LT centres have employed it pre-emptively before haemodynamic instability occurs to facilitate controlled reperfusion. This benefit is offset by complications which are directly attributable to ECMO including haemorrhage, thrombosis and systemic inflammatory responses. This systematic review synthesised the available data comparing the efficacy of ECMO to ‘off-pump’ strategies in LT. The primary outcome was patient survival. Secondary outcomes included time to extubation, ICU and hospital length of stay, primary graft dysfunction and need for renal replacement therapy (RRT). 6 retrospective studies were included with a total of 1008 patients. ECMO use was associated with worse survival, and longer time to extubation and LOS. A sub-group analysis separated unplanned ECMO from planned ECMO and found similarly inferior outcomes. The meta-analysis suffers from the same selection bias as the included studies. ECMO was utilised in cases of poor pre-operative factors (planned) or intra-operative complications (unplanned) and predictably, these patients had worse outcomes. In fact, the only included study which did compare planned ECMO to off pump strategies with similar patients in both groups showed superior outcomes in the ECMO group. The authors conclusion that ECMO is associated with poorer outcomes may be correct, but this meta-analysis has not demonstrated that this relationship is causal.
Trial registration
PROSPERO - CRD42025639316