We read with great interest the article by Goldberg and co-workers describing the successful transplantation of a brain-dead donor supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO) after cardiac arrest secondary to pulmonary embolism.1 Indeed, the considerable renewed interest in and accumulating evidence for the use of ECMO during the past few years is likely attributable to the observed improvements in extracorporeal technology.2,3 Even if the cause of the cardiac arrest was different, we have described a similar case 6 years ago.4 The important concept remains that after a refractory cardiac arrest, ECMO can be used until the resumption of a correct heart function, and later if the presence of brain death is noted, the process can be activated for harvesting the heart.
In this regard, we would like to add a comment regarding the present burning question. Medical teams may be reluctant to retrieve the heart from resuscitated donor cardiac arrest due to concerns on posttransplant outcomes, and pedagogic physiopathologic explanations are mandatory. Indeed, massive pulmonary embolism resulting in obstructive cardiogenic shock with right ventricular failure is a reversible mechanical disease.5,6 In fact, it has been shown that the hemodynamic restoration compatible with the weaning of circulatory assistance occurred after a few days under ECMO and therapeutic anticoagulation.7 Conversely, cardiac arrest on massive pulmonary embolism can have dreadful consequences on the neurologic prognosis. In fact, the central obstruction of the pulmonary arteries can reduce the effectiveness of cardiopulmonary resuscitation on its relative cerebral protection for two reasons: reduction in left ventricular preload related to a low transpulmonary blood flow with a concomitant reduction in anterograde cerebral perfusion generated by cardiac massage, and decrease in cerebral venous return (related to an increase in central venous pressure) with an increase in cerebral blood volume and intracranial pressure. As a result, these patients are at greater risk of having neurologic sequelae, or even worse, of being brain dead, whereas cardiac recovery is more likely and merits careful assessment of recovery of cardiac function. A critical question remains: can these hearts resist the ischemic injury of procurement, storage, and transportation? Currently, Organ Care Systems, capable of perfusing, preserving and improving the cardiac function of not irremediably compromised hearts are emerging.8
The prevalence of heart failure (HF) continues to increase worldwide. Heart transplantation is the most effective treatment for people experiencing end-stage HF whose quality of life and life expectancy are unacceptable.9 Unfortunately, imbalances between donors and the increasing number of patients needing transplantation lead to increases in waiting list mortality. The ultimate goal is to increase the number of heart donors which is currently insufficient to transplant patients with end-stage heart failure on the waiting list.
To date, there are minimal data on ECMO in donors experiencing cardiac arrest and undergoing heart transplantation.10 In particular cases, the use of ECMO is the sole attempt of saving the patient, and the unfortunate cerebral insult that ensues shifts the goals toward optimization of potentially transplantable organs. The question of ECMO in heart donation after cardiac arrest (death after circulatory death) is complex and raises both technical (timely cannulation with the exclusion of the cerebral circulation) and major ethical issues (the donor ceases to be “nonheart beating” once the coronary circulation is restored). Whether or not this is a potential field for donor heart expansion is uncertain and deserves dedicated research.
1. Goldberg JB, Levine A, Ohira S, Spielvogel D, Kai M: Successful heart transplantation recovered from a brain-dead donor on veno-arterial extracorporeal membrane oxygenation support. ASAIO J 2022;68:e92.
2. Banfi C, Bendjelid K, Giraud R: Conversion from percutaneous venoarterial extracorporeal membrane oxygenation access to a peripheral arterial cannulation: Is it safe? J Thorac Cardiovasc Surg 147: 1995–1996, 2014.
3. Banfi C, Pozzi M, Brunner ME, et al.: Veno-arterial extracorporeal membrane oxygenation: An overview of different cannulation techniques. J Thorac Dis 8: E875E885, 2016.
4. Arroyo D, Gasche Y, Banfi C, Stiasny B, Bendjelid K, Giraud R: Successful heart transplantation after prolonged cardiac arrest and extracorporeal life support in organ donor: A case report. J Cardiothorac Surg 10: 186, 2015.
5. Giraud R, Banfi C, Siegenthaler N, Bendjelid K: Massive pulmonary embolism leading to cardiac arrest: One pathology, two different ECMO modes to assist patients. J Clin Monit Comput 30: 933937, 2016.
6. Pavlovic G, Banfi C, Tassaux D, et al.: Peri-operative massive pulmonary embolism management: Is veno-arterial ECMO a therapeutic option? Acta Anaesthesiol Scand 58: 12801286, 2014.
7. Giraud R, Laurencet M, Assouline B, De Charriere A, Banfi C, Bendjelid K: Can VA-ECMO be used as an adequate treatment in massive pulmonary embolism? J Clin Med 10: 3376, 2021.
8. Stamp NL, Shah A, Vincent V, et al.: Successful heart transplant after ten hours out-of-body time using the transmedics organ care system. Heart Lung Circ 24: 611613, 2015.
9. Aissaoui N, Morshuis M, Maoulida H, et al.: Management of end-stage heart failure patients with or without ventricular assist device: An observational comparison of clinical and economic outcomes. Eur J Cardiothorac Surg 53: 170177, 2018.
10. Scheuer SE, Jansz PC, Macdonald PS: Heart transplantation following donation after circulatory death: Expanding the donor pool. J Heart Lung Transplant 40: 882–889, 2021.