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Extracorporeal membrane oxygenation (ECMO) is increasingly used with various indications. The clinical course can be complicated by an abdominal compartment syndrome (ACS). A decompressive laparotomy (DL) can be an option.Between 2014 and 2016 175 patients underwent ECMO support. Indications, demographic data, comorbidities, morbidity, mortality and length of stay were analyzed.Indications for ECMO were acute respiratory distress syndrome (n = 65), postpericardiotomy syndrome (n = 37), myocardial infarction (n = 26), extracorporeal cardiopulmonary resuscitation (n = 11), and others (n = 36). ECMO support was performed as veno-venous (VV, n = 91) or veno-arterial (VA, n = 84). Eleven patients developed ACS (VV-ECMO: n = 4; VA-ECMO: n = 7) and underwent DL. Three patients survived to hospital discharge. Risk factors were age (57 vs. 60.5 years, P = 0.032), a Charlson comorbidity index >1 (CCI, P = 0.004), a Simplified Acute Physiology Score (SAPS II) ≥ 42 at admission to ICU (P = 0.013) and ≥44 at the beginning of ECMO support (P = 0.004). When an ACS/DL occurred, mortality did not differ (DL: n = 11; 73% vs. no DL: n = 164; 65%; P = 0.749). Multivarate analysis revealed CCI and SAPS as independent predictors for mortality.Approximately 10% of patients undergoing VA-ECMO support developed an ACS. If DL is undertaken, SAPS II scores can be used as predictive factor for mortality.ECMO support is frequently complicated by an abdominal compartment syndrome.Risk for ACS is higher in patients with veno-arterial ECMO support.Decompressive laparotomy should be undertaken as salvage therapy.Elevated SAPS II scores can predict unfavorable outcome.