A Narrative Review on ECMO as a Bridge to Transplantation: Optimising Outcomes in Heart and Lung Failure

Extracorporeal membrane oxygenation (ECMO) provides short-term cardiopulmonary support for patients with end-stage heart and lung failure and is increasingly used as a bridge to transplantation. Its expanding clinical role has prompted the need to clarify how patient selection, timing of initiation, and complication risks influence transplant eligibility and outcomes. This review aims to evaluate contemporary evidence on ECMO as a bridge to heart and lung transplantation by outlining selection criteria, analysing the timing of intervention, summarising survival and complication data, and identifying the limitations that prevent consistent clinical standardisation. For the selection of articles, a narrative review approach was used. Articles were screened from PubMed and Rayyan, restricted to English-language studies published within the past 15 years, using the search terms "ECMO", "heart failure", and "lung failure". Paediatric studies and non-English literature were excluded. Across the literature, patient selection is guided by absolute contraindications (e.g., chronic multiorgan dysfunction, unrecoverable primary cardiac disease) and relative contraindications such as advanced age. Early initiation of ECMO is consistently associated with improved survival. The venoarterial (VA)-ECMO and venovenous (VV)-ECMO provide critical cardiac and respiratory support with varying survival outcomes; however, the therapy is associated with substantial clinical risks, including renal failure, significant bleeding, systemic infection, and vascular complications such as stroke or limb ischaemia. Prolonged bridging due to donor shortages further complicates outcomes and limits comparability across centres. Thus, it reinforces that ECMO is a crucial bridge to heart and lung transplantation. However, its effectiveness depends on precise patient selection, early and standardised initiation strategies, and unified clinical guidelines. Improved standardisation and consistent reporting are essential to optimise outcomes and strengthen long-term post-transplant evidence.