Data on the outcome of veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) support as a bridge to replacement therapies are scarce.

We investigated the outcome of V-A-ECMO support after adult cardiac surgery as a bridge to ventricular assist device (VAD) implantation and/or heart transplantation.

This is a retrospective, multicenter study recruiting patients who underwent heart transplantation or VAD implantation immediately after postcardiotomy V-A-ECMO for persistent heart failure at 14 European centers of cardiac transplantation from 2010 to 2024.

Ninety-four consecutive patients were treated at 14 European centers of cardiac transplantation from 2010 to 2024. In-hospital mortality after replacement therapy was 31.9%, while it was 35.2% (19/54 patients) after primary VAD implantation and 27.5% (11/40 patients) after primary heart transplantation (p = 0.429) after V-A-ECMO. Five-year all-cause mortality of the overall series was 52.4%. Five-year mortality was 66.0% after primary VAD and 32.7% after primary heart transplantation (adjusted HR 0.420, 95%CI 0.199–0.885). Sixty-four patients underwent heart transplantation any time after V-A-ECMO support and had a 5-year mortality rate of 34.9%, while it was 83.9% among 32 patients who received VAD support only (p < 0.0001).

The present findings support a bridge policy to heart replacement in selected postcardiotomy V-A-ECMO patients. Primary heart transplantation after V-A-ECMO support may be associated with better survival. The small size of this series and its results suggest that a larger study is needed to confirm these findings and could strengthen external validity and enhance the applicability of the results across different healthcare settings.