Feasibility and safety of awake extracorporeal membrane oxygenation for operating room extubation after lung transplantation.

Background: This study aimed to evaluate the feasibility and safety of awake extracorporeal membrane oxygenation (ECMO) for operating room (OR) extubation after lung transplantation (LTx). Methods: LTx patients, with intraoperative ECMO and extubation in the OR under ECMO support between January 1, 2024, and June 30, 2025, were classified as the awake ECMO + no mechanical ventilation (MV) group. From September 1, 2019 to December 31, 2023, the LTx patients, who weaned from ECMO in OR and subsequently extubated in the intensive care unit (ICU) were defined as the No ECMO + MV group, while those weaned from ECMO and extubated both in the ICU were classified as ECMO + MV group. Results: Forty-four LTx patients were extubated in the OR under awake ECMO support. After propensity score matching (PSM), 26 LTx patients were respectively included in three groups. No significant differences of vital signs were observed at the end of transplantation among the three groups (P>0.05), except that a lower central venous pressure and lower driving pressure in the ECMO + No-MV group (P=0.05 and P=0.001). The duration of invasive MV and ICU stay were shortest in ECMO + No MV group (P<0.001 and P=0.01). The ECMO-related complications and complications within postoperative 7 days had no difference among three groups (P=0.07 and P=0.053). The total cost of hospitalization was lowest in the No ECMO + MV group (P=0.02). The follow-up 3- and 6-month survivals were lowest in the ECMO + MV group (P<0.001 and P=0.02), while the follow-up 12-month survival was comparable among three groups (P=0.20). Conclusions: Extubated awake veno-arterial (VA)-ECMO is feasible and safe for OR extubation following LTx and may facilitate postoperative recovery by reducing invasive MV and ICU stay.