Brain death is common after extracorporeal cardiopulmonary resuscitation (eCPR): An undesired outcome with potential benefits

Mortality after cardiac arrest remains high despite advances in resuscitation and post-resuscitation care, with most patients dying before hospital discharge or sustaining severe hypoxic-ischaemic brain injury (HIBI). While the majority of these deaths follow withdrawal of life-sustaining treatment, a substantial proportion of patients progress to brain death (BD) as a direct consequence of HIBI, creating an opportunity for organ donation. Despite prolonged whole-body ischaemia-reperfusion, patients who develop BD after cardiac arrest are suitable organ donors, and current ERC-ESICM guidelines recommend their systematic identification. BD is more frequent following extracorporeal cardiopulmonary resuscitation (eCPR) than conventional CPR, reflecting the longer low-flow intervals tolerated in refractory arrest. This review synthesises the evidence on the frequency of BD and organ donation after cardiac arrest, with particular attention to the eCPR population. Although the benefit of eCPR in terms of favourable neurological survival remains debated—supported by inconsistent randomised trial results—organ donation represents an important secondary benefit for patients who do not survive. Reported composite benefit (survival or donation of at least one solid organ) reaches approximately one quarter of treated patients, and donated organs appear viable on follow-up. Maintenance costs of these donors are low given short ICU stays, strengthening the cost-effectiveness argument. Prompt detection of BD, timely donor identification, and empathic family engagement are essential. Prospective studies are warranted to confirm long-term graft viability.