Research Article| Volume 58, P179-184, March 2023

Outcomes of extracorporeal membrane oxygenation in immunosuppressed vs. Immunocompetent patients

Published:December 17, 2022DOI:


      • We compared the outcomes of immunocompetent patients, chronically immunosuppressed patients, and acutely immunosuppressed patients who were placed on ECMO at our institution.
      • There was no significant difference in ECMO, 30-day, 90-day, or one-year survival between immunocompetent patients, chronically immunosuppressed patients, and acutely immunosuppressed patients, suggesting that select immunosuppressed patients may be eligible for ECMO therapy.
      • Acutely immunosuppressed patients were at higher risk of developing new infections on ECMO, suggesting that infection control on ECMO is important in acutely immunosuppressed patients.



      Immunosuppressed hosts represent a growing group of patients who suffer acute respiratory failure and may be considered for therapies such as extracorporeal membrane oxygenation (ECMO).


      We conducted this retrospective study to determine whether acutely or chronically immunosuppressed patients placed on ECMO for cardiac and/or respiratory failure in our institution have different outcomes than immunocompetent patients placed on ECMO in our institution.


      Adult patients placed on ECMO between June 31, 2010 and July 7, 2021 were identified within an IRB-approved database. Data was retrospectively extracted from the database and patients’ medical records. Patients who survived ECMO decannulation were sub-grouped by the presence of acute or chronic immunosuppression, defined by the use of high-dose steroids or immunosuppressive agents for greater than four weeks prior to ECMO initiation. We analyzed and compared baseline characteristics and clinical outcomes using chi-squared tests for categorical variables and a one-way analysis of variance (ANOVA) for continuous variables.


      385 patients were included in this study, with 39 identified as chronically immunosuppressed, 49 as acutely immunosuppressed, and 297 as immunocompetent. There was no statistical difference in ECMO survival (respectively 54%, 59%, 65% p = 0.359) or 30-day survival (33%, 51%, 48% p = 0.149) for chronically immunosuppressed, acutely immunosuppressed, and immunocompetent, respectively. There were significant differences in rates of pre-ECMO COVID infection (p<0.001), coronary artery disease (p<0.001), smoking (p = 0.003), and acute kidney injury (p = 0.032). Acutely immunosuppressed patients had the highest rates of new infections during ECMO (p = 0.006).


      When compared to immunocompetent patients, both acutely and chronically immunosuppressed patients had no significant difference in ECMO survival or 30-day survival. Acutely immunosuppressed patients had less comorbidities than chronically immunosuppressed patients, but they were more commonly infected during ECMO. ECMO may still be a valuable tool in appropriately selected patients with refractory respiratory or cardiac failure.



      ECMO (Extracorporeal membrane oxygenation), COVID-19 (Coronavirus disease-2019), ARDS (Acute respiratory distress syndrome)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart & Lung: The Journal of Cardiopulmonary and Acute Care
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Sidebotham D.
        • McGeorge A.
        • McGuinness S.
        • et al.
        Extracorporeal membrane oxygenation for treating severe cardiac and respiratory disease in adults: part 1—overview of extracorporeal membrane oxygenation.
        J. Cardiothorac. Vasc. Anesth. 2009; 23: 886-892
        • Ratnani I.
        • Tuazon D.
        • Zainab A.
        • et al.
        The role and impact of extracorporeal membrane oxygenation in critical care.
        Methodist Debakey Cardiovasc J. 2018; 14: 110-119
        • Awsare B.
        • Herman J.
        • Baram M.
        Management strategies for severe respiratory failure: as extracorporeal membrane oxygenation is being considered.
        Crit Care Clin. 2017; 33: 795-811
        • Shekar K.
        • Slutsky A.S.
        • Brodie D.
        ECMO for severe ARDS associated with COVID-19: now we know we can, but should we?.
        Lancet Respir Med. 2020; 8: 1066-1068
        • Schmidt M.
        • Langouet E.
        • Hajage D.
        • et al.
        Evolving outcomes of extracorporeal membrane oxygenation support for severe COVID-19 ARDS in Sorbonne hospitals, Paris.
        Critical Care. 2021; 25: 355
        • George M.P.
        • Masur H.
        • Norris K.A.
        • et al.
        Infections in the immunosuppressed host.
        Ann Am Thorac Soc. 2014; 11: S211-S220
        • Cortegiani A.
        • Madotto F.
        • Gregoretti C.
        • et al.
        Immunocompromised patients with acute respiratory distress syndrome: secondary analysis of the LUNG SAFE database.
        Crit Care. 2018; 22: 157
        • Harnisch L.O.
        • Moerer O.
        Contraindications to the initiation of Veno-Venous ECMO for severe acute respiratory failure in adults: a systematic review and practical approach based on the current literature.
        Membranes (Basel). 2021; 11: 584
        • Fishman J.A.
        Opportunistic Infections—coming to the limits of immunosuppression?.
        Cold Spring Harb Perspect Med. 2013; 3a015669
        • Wallace B.I.
        • Kenney B.
        • Malani P.N.
        • et al.
        Prevalence of immunosuppressive drug use among commercially insured US adults, 2018-2019.
        JAMA Netw. Open. 2021; 4e214920
        • Azoulay E.
        • Russell L.
        • Van de Louw A.
        • et al.
        Diagnosis of severe respiratory infections in immunocompromised patients.
        Intensive Care Med. 2020; 46: 298-314
        • Tonna J.E.
        • Abrams D.
        • Brodie D.
        • et al.
        Management of adult patients supported with venovenous extracorporeal membrane oxygenation (VV ECMO): guideline from the extracorporeal life support organization (ELSO).
        ASAIO J. 2021; 67 (Jun 1PMID: 33965970; PMCID: PMC8315725.)): 601-610
        • Hong J.
        • Choi C.H.
        Extracorporeal membrane oxygenation support in patients with hematologic malignancies: to whom and when?.
        Korean J Intern Med. 2017; 32 (NovEpub 2017 Oct 23. PMID: 29056036; PMCID: PMC5668400): 1116-1118
        • Wohlfarth P.
        • Ullrich R.
        • Staudinger T.
        • et al.
        Arbeitsgruppe für hämato-onkologische Intensivmedizin der Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin (ÖGIAIN). Extracorporeal membrane oxygenation in adult patients with hematologic malignancies and severe acute respiratory failure.
        Crit Care. 2014; 18 (Jan 20PMID: 24443905; PMCID: PMC4055976): R20
        • Schmidt M.
        • Schellongowski P.
        • Patroniti N.
        • IDEA Study Group collaborators are as follows
        Six-month outcome of immunocompromised patients with severe acute respiratory distress syndrome rescued by extracorporeal membrane oxygenation. An international multicenter retrospective study.
        Am J Respir Crit Care Med. 2018; 197 (May 15PMID: 29298095; PMCID: PMC7252852): 1297-1307
        • Bein T.
        • Weber-Carstens S.
        Extracorporeal life support in immunocompromised patients with severe acute respiratory distress syndrome. decide wisely, early, and in a personalized way.
        Am J Respir Crit Care Med. 2018; 197 (May 15PMID: 29350972): 1241-1243
        • Rozencwajg S.
        • Bréchot N.
        • Schmidt M.
        • et al.
        Co-infection with influenza-associated acute respiratory distress syndrome requiring extracorporeal membrane oxygenation.
        Int J Antimicrob Agents. 2018; 51: 427-433
        • Cheng A.
        • Sun H.Y.
        • Tsai M.S.
        • et al.
        Predictors of survival in adults undergoing extracorporeal membrane oxygenation with severe infections.
        J Thorac Cardiovasc Surg. 2016; 152 (e1): 1526-1536
        • Blazoski C.
        • Yang Q.
        • Hirose H.
        Outcomes of extracorporeal membrane oxygenation in blood culture positive septic patients.
        World J Cardiovasc Surg. 2020; 10: 158-166
        • Thangappan K.
        • Cavarocchi N.C.
        • Baram M.
        • et al.
        Systemic inflammatory response syndrome (SIRS) after extracorporeal membrane oxygenation (ECMO): incidence, risks and survivals.
        Heart Lung: J Cardiopul Acute Care. 2016; 45: 449-453
        • Schmidt M.
        • Schellongowski P.
        • Patroniti N.
        • et al.
        Six-month outcome of immunocompromised patients with severe acute respiratory distress syndrome rescued by extracorporeal membrane oxygenation. an international multicenter retrospective study.
        Am J Respir Crit Care Med. 2018; 197: 1297-1307
      1. Lewis T.C., Arnouk S., Toy B., et al. Tocilizumab accelerates recovery in patients with severe COVID-19 pneumonia on venovenous extracorporeal membrane oxygenation. ASAIO J..:10.1097/MAT.0000000000001707. doi:10.1097/MAT.0000000000001707

        • Badulak J.
        • Antonini M.V.
        • Stead C.M.
        • et al.
        Extracorporeal membrane oxygenation for COVID-19: updated 2021 guidelines from the extracorporeal life support organization.
        ASAIO J. 2021; 67: 485-495
        • Vuylsteke A.
        ECMO in COVID-19: do not blame the tool.
        The Lancet. 2021; 398: 1197-1199
        • Fung M.
        • Babik J.M.
        COVID-19 in immunocompromised hosts: what we know so far.
        Clin Infect Dis. 2020; (Published online June 27): ciaa863
        • Martínez-Urbistondo M.
        • Gutiérrez-Rojas Á.
        • Andrés A.
        • et al.
        Severe lymphopenia as a predictor of COVID-19 mortality in immunosuppressed patients.
        J Clin Med. 2021; 10: 3595