Extracorporeal membrane oxygenation in organ donation and organ preservation

Extracorporeal membrane oxygenation (ECMO) has evolved from a rescue intervention for severe cardiac and respiratory failure into a platform supporting organ donation and transplantation. Although its role in bridging patients to transplantation is well established, its contribution to donor optimization and organ preservation is increasingly recognized. A significant proportion of patients treated with ECMO do not survive and thus represent a potential source of donor organs. Organ donation in such patients has certain challenges but significant potential advantages. ECMO can maintain hemodynamic stability and organ perfusion while awaiting retrieval. Available observational evidence on graft outcomes from ECMO donors is positive but is currently limited to retrospective studies. For controlled donation after circulatory death, pre-existing ECMO cannulation offers a distinct advantage: rapid establishment of normothermic regional perfusion, minimizing warm ischaemia, which has been associated with improved graft outcomes, particularly in liver transplantation. Extracorporeal cardiopulmonary resuscitation and uncontrolled donation after cardiac death programs introduce additional opportunities and complexities. These pathways share infrastructure and expertise, but decisions to initiate or discontinue resuscitation must remain independent of donation considerations. ECMO has become an integral component of the transplantation pathway from support of the critically ill patient, extending beyond death to organ preservation and transplantation. Wider implementation requires coordinated multidisciplinary teams, standardized protocols, appropriate resource allocation and robust clinical and ethical governance. Prospective multicenter research is needed to clarify donor selection, organ utilization, long-term graft outcomes and cost-effectiveness as ECMO's role within the transplantation pathway continues to grow.