Cardiac arrest is a rare but critical complication during the management of donors declared dead by neurological criteria (donation after brain death). We report the case of a 56-year-old male donor after brain death who developed sudden cardiac arrest shortly before planned organ procurement. Despite prolonged cardiopulmonary resuscitation and progression to asystole, organ retrieval was initiated with ongoing resuscitative measures and vasoactive support. The liver was successfully retrieved following hypothermic perfusion, demonstrated no significant histopathological injury, and was transplanted successfully. This case highlights the feasibility of organ recovery following cardiac arrest in donation after brain death donors and emphasizes the importance of preparedness, rapid multidisciplinary coordination, and robust protocols to optimize organ viability and expand the donor pool.

Key words : Donation after brain death, Donor pool, Multidisciplinary coordination, Organ viability

Introduction
Cardiac arrest is a rare but potential complication in the management of organs from donation after brain death. Death by neurological criteria is defined as the complete and irreversible loss of all brain function, including the brainstem. Donation after circulatory death (DCD)/postarrest donors represent an important population of potential organ donors. We briefly present and discuss a case of cardiac resuscitation of a patient who had been initially declared for donation after brain death and our experience in the management of this patient, with a pertinent review of the literature.

Case Report
A 56-year-old male patient was transferred to our hospital in a comatose state as a potential organ donor after being declared dead by neurological criteria due to traumatic brain injury. During the transport via ambulance, while on noradrenaline support he experienced a brief episode of atrial fibrillation but spontaneously reverted to sinus rhythm. He was then admitted to our intensive care unit (ICU) at 9:45 pm. Past medical history was significant for hypertension and acute kidney injury for which he underwent dialysis. The patient was closely monitored by the ICU team and was scheduled to undergo organ procurement the following day at 10:30 am. On the morning of the procedure, the patient was reviewed by the anesthesia team at 8:50 am and was cleared for transfer to the operation theater. However, at around 9:20 am, the donor went into sudden cardiac arrest while in the ICU; in response, cardiopulmonary resuscitation (CPR) was immediately started, followed by expedited transfer to the operation theater. The CPR protocol continued until 9:50 am; although there was a brief return of spontaneous circulation, the status quickly reverted to ventricular fibrillation. At 9:52 am, asystole was confirmed and the patient was transferred to the surgical team in the operation theater where CPR was continued. The surgery was started with ongoing CPR and continued infusion of adrenaline and noradrenaline. Hypothermic perfusion of the liver was started at 10:12 am, and the aorta was cross-clamped at 10:23 am. The liver was retrieved successfully. Core and wedge biopsy samples of the donor liver were sent for histopathology analysis. There were no signs of ischemia, necrosis, fibrosis, or cirrhosis. Hence, the liver was deemed viable and was successfully transplanted.

Discussion
Circulatory death is defined as the irreversible cessation of circulatory and respiratory function. In DCD, death is confirmed by sustained absence of cardiac activity and circulation using electrocardiographic, arterial waveform, or invasive pressure monitoring. These DCD donors represent an increasingly important source of transplantable organs. The Maastricht classification, initially proposed by Kootstra and colleagues and later refined through international consensus, provides a standardized framework for DCD categorization. In our present case, the donor, who was initially declared dead by neurological criteria and subsequently experienced cardiac arrest, meets criteria for Maastricht category IV DCD, a recognized but uncommon category.^1,2 Unexpected cardiac arrest in potential donors remains a major cause of donor loss. Hemodynamic instability, arrhythmias, endocrine dysfunction, and suboptimal donor optimization contribute significantly to this risk. Implementation of structured donor management protocols, early involvement of organ procurement organizations, and aggressive critical care optimization have been shown to reduce preventable donor cardiac arrest and to improve organ retrieval rates.³ Expansion of organ donation following cardiac arrest, including out-of-hospital cardiac arrest, has been proposed as a strategy to address the persistent donor shortage. Morrison and colleagues have described multiple pathways through which patients with unsuccessful resuscitation may still proceed to organ donation, and they highlighted limitations of the traditional Maastricht system in capturing these scenarios, advocating for revised classification and standardized donation pathways.⁴ Extracorporeal CPR has been suggested as a potential adjunct to preserve organ perfusion in selected cases; however, the role of extracorporeal CPR to facilitate organ donation remains investigational and requires further ethical and outcome-based evaluation.^4,5 Controlled DCD protocols emphasize careful candidate selection, shrewd prognostication of time to death following withdrawal of life-sustaining therapy, and strict separation between the end-of-life donation decision and the organ procurement event. Eligibility assessment, informed consent for premortem interventions, and independent death declaration are essential to maintain ethical and legal integrity.^2,6 These safeguards are particularly important in complex cases involving post arrest donors. Normothermic regional perfusion has emerged as a promising strategy to mitigate ischemia-reperfusion injury in DCD by restoration of oxygenated blood flow to abdominal organs while excluding cerebral circulation. Early evidence suggests that normothermic regional perfusion may improve graft function and utilization, particularly in high-risk DCD scenarios, and may be especially relevant in Maastricht category IV donors.^7,8 Our case demonstrates that cardiac arrest in a donor after brain death does not necessarily preclude successful organ recovery. With prompt recognition, adherence to protocolized management, and optimized perfusion strategies, viable organs can be retrieved under difficult circumstances, supporting broader and judicious expansion of the donor pool.

Conclusions
Our case underscores the critical significance of readiness for unforeseen cardiac incidents that may occur during the process of organ procurement from donors who are classified as brain death donors. Timely identification and intervention in instances of cardiac arrest can facilitate the successful recovery and transplant of organs, even under difficult conditions. Therefore, it remains crucial for organ procurement facilities to establish comprehensive protocols for the management of such events.