Utilization and outcomes of organs from ECMO-supported brain-dead donors: two-center experience

BACKGROUND: Organ shortages remain a critical global challenge, and extracorporeal membrane oxygenation (ECMO) has emerged as a potential strategy to preserve organ perfusion and expand the donation after brain death (DBD) donor pool. In regions where donation after circulatory death (DCD) is not legally permitted, maximizing DBD donor utilization carries particular clinical and policy importance. However, evidence regarding organ-specific recovery rates and post-transplant graft outcomes in ECMO-supported DBD donors remains limited and heterogeneous. METHODS: We conducted a two-center retrospective cohort study of all consecutive brain-dead organ donors managed at two tertiary referral centers between January 2012 and June 2025. Donors were stratified by ECMO exposure prior to organ procurement. Primary outcomes were organ-specific recovery rates and the number of organs recovered per donor. Kaplan-Meier analysis with log-rank testing was used to evaluate post-transplant recipient survival stratified by donor ECMO exposure and organ type. RESULTS: Of 210 donors (ECMO n=25, non-ECMO n=185), baseline demographics and cause of brain death were broadly comparable, although ECMO donors more frequently had antecedent cardiac arrest (76.0% vs 53.5%, P=0.001), reflecting a population that would likely not have survived to brain death determination without extracorporeal support. Thoracic organ recovery was markedly lower in the ECMO group (heart 4.2% vs 47.6%; lung 4.2% vs 47.0%; both P<0.001), attributable primarily to underlying cardiopulmonary pathology. Abdominal organ recovery was preserved, with comparable rates for liver (75.0% vs 84.3%, P=0.586) and kidneys (right 87.5% vs 89.7%, P=0.845; left 87.5% vs 91.4%, P=0.649). Recipient survival was comparable across organ types; for liver grafts, ECMO-derived organs maintained higher survival probability at late follow-up (log-rank P=0.02), a hypothesis-generating finding that should be interpreted with caution given the small number of events. CONCLUSIONS: ECMO-supported donors can preserve abdominal organ viability and achieve post-transplant recipient survival comparable to conventional DBD donors, although these findings are exploratory given the small sample size and retrospective design. Whether structured ECMO use represents a meaningful strategy for donor pool expansion, particularly in settings where DCD is unavailable, warrants confirmation in larger prospective studies.