Organ donation under V-A ECMO support: insights and recommendations from Japan's first two cases.

Background: The use of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has expanded globally as a life-saving intervention of cardiac arrest. However, brain death following successful resuscitation presents unique clinical and procedural challenges, particularly in apnea testing, electroencephalographic (EEG) monitoring, and organ donation. Despite increasing international adoption of ECMO, standardized protocol for brain death determination under ECMO remain limited. Methods: This study describes Japan's first two cases of legal brain death determination and organ donation under V-A ECMO support, conducted in accordance with Japan's legal standards. Each case was managed through close multidisciplinary collaboration and tailored clinical planning. Key procedural challenges were addressed, including adaptation of apnea testing via controlled sweep gas flow reduction, minimization of EEG artifacts through strategic technical adjustments, and intraoperative planning to ensure stable organ perfusion. Based on these experiences, we developed an institutional protocol to support safe and standardized brain death determination and organ retrieval under ECMO. Results: Both cases were successfully completed without significant complications, offering valuable insights into ECMO-assisted organ donation. Key considerations included optimizing sweep gas flow to achieve PaCO Conclusion: This study suggests that brain death organ donation under ECMO can be performed under specific conditions, even in countries where its adoption has been limited. Establishing a safe and standardized determination process may enhance organ donation and expand the pool of transplantable organs.