Key Characteristics Impacting Survival of COVID-19 Extracorporeal Membrane Oxygenation

Johannes Herrmann; Christopher Lotz; Christian Karagiannidis; Steffen Weber-Carstens; Stefan Kluge; Christian Putensen; Andreas Wehrfritz; Karsten Schmidt; Richard K. Ellerkmann; Daniel Oswald; Gösta Lotz; Viviane Zotzmann; Onnen Moerer; Christian Kühn; Matthias Kochanek; Ralf Muellenbach; Matthias Gaertner; Falk Fichtner; Florian Brettner; Michael Findeisen; Markus Heim; Tobias Lahmer; Felix Rosenow; Nils Haake; Philipp M. Lepper; Peter Rosenberger; Stephan Braune; Mirjam Kohls; Peter Heuschmann; Patrick Meybohm


Crit Care. 2022;26(190) 

In This Article

Abstract and Introduction


Background: Severe COVID-19 induced acute respiratory distress syndrome (ARDS) often requires extracorporeal membrane oxygenation (ECMO). Recent German health insurance data revealed low ICU survival rates. Patient characteristics and experience of the ECMO center may determine intensive care unit (ICU) survival. The current study aimed to identify factors affecting ICU survival of COVID-19 ECMO patients.

Methods: 673 COVID-19 ARDS ECMO patients treated in 26 centers between January 1st 2020 and March 22nd 2021 were included. Data on clinical characteristics, adjunct therapies, complications, and outcome were documented. Block wise logistic regression analysis was applied to identify variables associated with ICU-survival.

Results: Most patients were between 50 and 70 years of age. PaO2/FiO2 ratio prior to ECMO was 72 mmHg (IQR: 58–99). ICU survival was 31.4%. Survival was significantly lower during the 2nd wave of the COVID-19 pandemic. A subgroup of 284 (42%) patients fulfilling modified EOLIA criteria had a higher survival (38%) (p = 0.0014, OR 0.64 (CI 0.41–0.99)). Survival differed between low, intermediate, and high-volume centers with 20%, 30%, and 38%, respectively (p = 0.0024). Treatment in high volume centers resulted in an odds ratio of 0.55 (CI 0.28–1.02) compared to low volume centers. Additional factors associated with survival were younger age, shorter time between intubation and ECMO initiation, BMI > 35 (compared to < 25), absence of renal replacement therapy or major bleeding/thromboembolic events.

Conclusions: Structural and patient-related factors, including age, comorbidities and ECMO case volume, determined the survival of COVID-19 ECMO. These factors combined with a more liberal ECMO indication during the 2nd wave may explain the reasonably overall low survival rate. Careful selection of patients and treatment in high volume ECMO centers was associated with higher odds of ICU survival.

Trial Registration: Registered in the German Clinical Trials Register (study ID: DRKS00022964, retrospectively registered, September 7th 2020,

Graphical abstract


The COVID-19 pandemic is challenging intensive care providers due to severe and prolonged cases of COVID-19 induced acute respiratory distress syndrome (ARDS). Compromised gas exchange may deteriorate despite maximum medical care, whereas veno-venous extracorporeal membrane oxygenation (VV ECMO) offers the chance to uphold oxygenation, carbon dioxide removal and rest the lungs. Although ECMO provides a rescue strategy and bridge to recovery, its use is resource intensive and can be associated with serious complications. In Germany, ECMO utilization had already increased manifold prior to the COVID-19 pandemic.[1]

Need and indications of ECMO support are not universally defined but vary between centers and resource availability. In a pandemic ECMO use likely follows a U-shaped curve. A high number of patients are treated as COVID-19 numbers rise, decrease when hospital strain exceeds their capabilities and may rise again as strain eases.[2] In contrast to other countries, the German health care system was not overloaded during the COVID-19 pandemic.[3] In this context, patients with a lower, but reasonable probability of survival received ECMO support and numerous low to high volume ECMO centers treated COVID-19 ARDS patients. Recent health insurance data including more than 4000 VV ECMO patients surprisingly revealed a hospital survival rate of only 34%, thus further detailed structural and patient related analyses are urgently needed.[4]

The continuous provision of organizational structures for successful ECMO therapy is challenging and during the pandemic less experienced centers have been faced with an increased number of ECMO patients, necessitating careful planning and training.[5] In this regard, effectiveness of low volume centers had already been questioned in non-COVID ECMO. In previous studies, admission to hospitals treating more than 30[6] or more than 50[7] ECMO patients per year was associated with a lower mortality in veno-arterial ECMO (VA ECMO). However, volume-outcome relationships have been less frequently defined in VV ECMO. An analysis of the Extracorporeal Life Support Organization Registry found no significant association between center volumes and patient survival in non-COVID respiratory assist.[6] Nonetheless, a position paper of renowned experts recommended that respiratory ECMO programs should treat at least 20 patients per year, including 12 respiratory cases.[8] Moreover, a recent study found that centers with longer experience with COVID-19 ECMO had a lower mortality rate relative to centers that started COVID-19 ECMO at a later timepoint.[9]

We performed a multicenter study aiming to delineate the characteristics of ECMO therapy for COVID-19 induced ARDS, as well as to identify structural and patient-related factors independently associated with early survival of intensive care unit (ICU) treatment.