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.

Heart failure imposes a significant burden on all health care systems and has a 5-year mortality of 50%. Heart transplantation and ventricular assist device (VAD) implantation are the definitive therapies for end stage heart disease, although transplantation appears to offer superior long-term survival and quality of life over VAD implantation. Transplantation is limited by a shortage in donor hearts, resulting in considerable waiting list mortality. Donation after circulatory determination of death (DCD) offers a significant uplift in the number of donors for heart transplantation. The outcomes both from the UK and internationally have been exciting, with outcomes at least as good as conventional donation after brain death (DBD) transplantation. Currently, DCD hearts are reperfused using ex-situ machine perfusion (ESMP). Whilst ESMP has enabled the development of DCD transplantation, it comes at significant cost, with the per run cost of approximately GBP £90,000. In-situ perfusion of the heart, otherwise known as thoraco-abdominal normothermic regional perfusion (taNRP) is cheaper, but there are ethical concerns regarding the potential to restore cerebral perfusion in the donor. We must determine whether there is any cerebral circulation during in-situ perfusion of the heart to ensure that it does not invalidate the diagnosis of death and potentially violate the dead donor rule. Besides this, there is a need for a randomised controlled trial to definitively determine whether taNRP offers any clinical advantages over ex-situ machine perfusion. This viewpoint article explores these issues in more detail.

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.

We examine the emergence of the ‘postfeminist’ sensibility from feminist theory and praxis, and its relation and relevance to education. Analytical frameworks such as postfeminism and intersectionality have given equal weight to recognition-based struggles, such as those based on sexual, racial, class-based, gender-related identities. We follow Nancy Fraser’s argument that these identity-based movements have been co-opted by neoliberal politicians and bureaucratic policy-makers, and become a divide and rule strategy, neglecting the subjugating power of capital. Beginning with third-wave feminism’s emphasis on individual identity, women’s struggles have been become a part of the greater parisitic neoliberal project. We consider the implications of this docile and domesticated feminism for the education of women.