Another important consideration in the development and implementation of an ambulatory ECMO program of this nature is time spent on the waiting list. As an example, at Duke, the average waiting time for lung transplantation is 18 days, compared with a national average of 110 days.2 The waiting time varies considerably by donation service area and institution, and the decision to initiate ECMO in patients in these settings must be weighed carefully. On one hand, life support may increase the likelihood of survival to transplantation, but longer time on ECMO increases risk for complications, such as thromboembolism, bleeding, stroke, infection, and renal failure.31 Studies have demonstrated decreased survival with increasing duration of ECMO, and it may be suggested that centers with shorter wait times (< 1 month) have the best chance to successfully bridge patients to transplant with the minimum number of complications and improved outcomes.32,33 However, a publication reported a patient with nonambulatory ECMO receiving a successful lung transplant after 107 days of ECMO support.34 Whether ambulatory or not, the long-term outcomes for patients receiving transplant following a prolonged course of ECMO are not yet known. The overall impact on both patients and programs of potentially prolonged durations of ECMO while awaiting lung transplant remains unclear, and this approach may not be the most efficient use of resources in centers with lower numbers of transplants or longer wait times. The decision to transfer patients who may require advanced support to a center with increased volume and shorter waiting times may provide patients with an increased opportunity for early transplantation to avoid complications and improve posttransplant outcomes.