**3. Conclusions**

VA ECMO as a BTT strategy is increasingly used after the change of allocation policies in many countries, particularly in the United States. Indeed, since patients supported with ECMO receive the highest priority status, this MCS has emerged as an attractive therapy to obtain at the same time cardiopulmonary support and to facilitate HTx.

However, since the ECMO-BTT strategy was traditionally burdened by high mortality, preventing any possible shifts of the limited available donor organ pool represents a major concern. Based on international experience, the key factors for obtaining successful HTx in patients supported with ECMO are as follows: 1—a thorough ECMO management aimed to prevent possible complications, while permitting end-organ recovery, 2—risk stratification and accurate selection of candidates at the time of listing, and 3—obtaining a compatible donor heart in relatively short time.

Otherwise, in high-risk conditions, transition to durable MCS should be considered to favor patient full recovery, permitting a judicious use of the limited donor pool.
