Impact of VA-ECMO Bridging on Heart Transplant: Outcomes and Complications

All articles of this category (opens in new window) Background: The recent change in the UNOS allocation policy in 2018 has led to a marked increase in the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge to transplantation (BTT) in patients with end-stage heart failure. Despite its growing application, evidence on outcomes and complications during VA-ECMO bridging remains limited. This retrospective single-center study aims to compare short- and long-term posttransplant outcomes between patients bridged with VA-ECMO and those transplanted without ECMO, and to identify key complications during ECMO support, particularly stroke and infection. Methods: A total of 394 patients between January 1, 2012, and January 1, 2022, were included, of whom 21 (5.3%) were bridged with VA-ECMO. One-year survival was assessed using the Kaplan–Meier method, and risk factors were analyzed using univariate and multivariate Cox regression models. A second analysis examined all patients evaluated for HTX on VA-ECMO ( n = 42), comparing the transplanted ( n = 21) and nontransplanted cohort ( n = 21). Results: One-year survival did not differ significantly between VA-ECMO and non-VA-ECMO groups ( p = 0.894). In the multivariate analysis, postoperative ECMO support emerged as the strongest independent predictor of 1-year mortality (HR= 4.18, 95% CI: 2.07–8.47, p < 0.001), followed by renal replacement therapy (HR=3.29, 95% CI: 1.58–6.84, p = 0.01) and elevated bilirubin at the time of transplantation (HR= 1.19; 95% CI: 1.03–1.38, p = 0.017). ECMO as BTT was not independently associated with reduced posttransplant survival (HR=0.5, 95% CI: 0.1–2.45, p = 0.393). Adverse events during ECMO occurred in 47.6% of patients, most frequently bleeding 23.81%, distal perfusion cannula dysfunction 28.56%, and heparin-induced thrombocytopenia 19.05%. Of 42 patients evaluated for HTX on VA-ECMO, only 21 underwent transplantation, while the remainder were weaned ( n = 4), died on support ( n = 3), or required durable MCS ( n = 14). Transplanted patients were younger, 41 (32–56) vs. 58 (46–63) years ( p = 0.002), with a different blood group distribution ( p = 0.044). Conclusion: VA-ECMO as BTT can achieve comparable 1-year survival to transplantation without ECMO when applied in carefully selected patients. However, its use is associated with a high incidence of complications, underscoring the importance of vigilant monitoring, structured management protocols, and multidisciplinary decision-making in this high-risk population. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany