Heart transplantation is an effective treatment offering the best recovery in both quality and quantity of life in those affected by refractory, severe heart failure. However, transplantation is limited by donor organ availability. The reintroduction of heart donation after the circulatory determination of death (DCD) in 2014 offered an uplift in transplant activity by 30%. Thoraco-abdominal normothermic regional perfusion (taNRP) enables in-situ reperfusion of the DCD heart. The objective of this paper is to assess the clinical outcomes of DCD donor hearts recovered and transplanted from donors undergoing taNRP. This was a multicentre retrospective observational study. Outcomes included functional warm ischaemic time, use of mechanical support immediately following transplantation, perioperative and long-term actuarial survival and incidence of acute rejection requiring treatment. 157 taNRP DCD heart transplants, performed between February 2, 2015, and July 29, 2022, have been included from 15 major transplant centres worldwide including the UK, Spain, the USA and Belgium. 673 donations after the neurological determination of death (DBD) heart transplantations from the same centres were used as a comparison group for survival. taNRP resulted in a 23% increase in heart transplantation activity. Survival was similar in the taNRP group when compared to DBD. 30-day survival was 96.8% ([92.5%-98.6%] 95% CI, n = 156), 1-year survival was 93.2% ([87.7%-96.3%] 95% CI, n = 72) and 5-year survival was 84.3% ([69.6%-92.2%] 95% CI, n = 13). Our study suggests that taNRP provides a significant boost to heart transplantation activity. The survival rates of taNRP are comparable to those obtained for DBD transplantation in this study. The similar survival may in part be related to a short warm ischaemic time or through a possible selection bias of younger donors, this being an uncontrolled observational study. Therefore, our study suggests that taNRP offers an effective method of organ preservation and procurement. This early success of the technique warrants further investigation and use. None of the authors have a financial relationship with a commercial entity that has an interest in the subject.

One concern about the use of normothermic regional perfusion (NRP) in controlled donation after the circulatory determination of death (cDCD) is that the brain may be perfused. We aimed to demonstrate that certain technical maneuvers preclude such brain perfusion. A nonrandomized trial was performed on cDCD donors. In abdominal normothermic regional perfusion (A-NRP), the thoracic aorta was blocked with an intra-aortic occlusion balloon. In thoracoabdominal normothermic regional perfusion (TA-NRP), the arch vessels were clamped and the cephalad ends vented to the atmosphere. The mean intracranial arterial blood pressure (ICBP) was invasively measured at the circle of Willis. Ten cDCD donors subject to A-NRP or TA-NRP were included. Mean ICBP and mean blood pressure at the thoracic and the abdominal aorta during the circulatory arrest were 17 (standard deviation [SD], 3), 17 (SD, 3), and 18 (SD, 4) mmHg, respectively. When A-NRP started, pressure at the abdominal aorta increased to 50 (SD, 13) mmHg, while the ICBP remained unchanged. When TA-NRP was initiated, thoracic aorta pressure increased to 71 (SD, 18) mmHg, but the ICBP remained unmodified. Recorded values of ICBP during NRP were 10 mmHg. In conclusion, appropriate technical measures applied during NRP preclude perfusion of the brain in cDCD. This study might help to expand NRP and increase the number of organs available for transplantation.

Heart transplantation from donors after the circulatory determination of death (DCDD) is expanding worldwide. Thoraco-abdominal normothermic regional perfusion (TA-NRP) allows the validation and recovery of the DCDD heart, but there is limited evidence on the results of heart transplants performed with this approach. This multicenter, nationwide, prospective study describes the short-term outcomes of adult patients receiving a DCDD heart transplant obtained via TA-NRP followed by static cold storage in Spain. Recipients of hearts from donors after the neurological determination of death (DNDD) were used as controls. The primary outcome was a composite of 1-year all-cause death or severe primary graft failure (PGF). During 2020-2023, 98 adult DCDD and 347 DNDD heart transplants were performed across 11 centers. The primary outcome was met by 21 (21.4%) and 77 (22.2%) patients, respectively (p=0.87). Thirty-day and 1-year survival were 94.9% and 88.8% in the DCDD vs 93.7% and 87.3% in the DNDD group (p=0.70). Severe PGF was observed in 13 (13.3%) vs 52 (15.0%) patients (p=0.67). By inverse probability weighting, the DCDD heart was not associated with the primary outcome (HR 0.97;95%CI 0.58-1.62;p=0.91). In conclusion, adult DCDD heart transplantation based on TA-NRP and static cold storage provides similar short-term outcomes than DNDD heart transplants.

Donation after circulatory death (DCD) transplantation offers an effective and safe method of increasing the number of heart transplants performed. The DCD heart is ischaemic at the time of retrieval and therefore requires reperfusion. This may take place in the donor - known as thoracoabdominal normothermic regional perfusion (taNRP) or outside of the donor, known as direct procurement and preservation (DPP). There is a growing body of evidence that taNRP is associated with better utilisation of thoracic and abdominal organs from the donor and with superior recipient outcomes. taNRP offers a cheaper alternative to organ recovery than DPP. In addition, taNRP can also be used in paediatric transplantation. However, there are still concerns regarding the ethical acceptability of taNRP. These concerns centre around the possible restoration of brain blood flow during taNRP through collaterals to the vertebrobasilar system. Early studies have demonstrated no brain blood flow or perfusion, but these are limited by small numbers. Further work, with significantly more cases, will need transatlantic collaboration to definitively establish the absence of brain blood flow or perfusion. We have a moral responsibility to both donors and recipients to expedite this work.