Cardiac function recovery after 20-min hands-off using thoracoabdominal-normothermic regional perfusion

Abstract

Background: The increasing prevalence of end-stage heart failure coupled with limited donor organs creates a critical need for novel strategies in heart transplantation. Donation after circulatory death offers a promising approach to expand the donor pool. Italian legislation mandates a prolonged "no-touch" period for death declaration, raising concerns about organ preservation. This study presents the initial experience of a single Italian center performing heart transplantation from donation after circulatory death donors.

Methods: We conducted a retrospective observational study of donation after circulatory death heart transplants performed from August 2023 to March 2025. Donor hearts underwent reconditioning via thoracoabdominal normothermic regional perfusion before procurement and were preserved in cold storage. Primary endpoints included 30-day mortality and severe primary graft dysfunction. Secondary endpoints encompassed intensive care unit (ICU) and hospital length of stay, post-operative complications, and echocardiographic assessment of graft function and rejection rates.

Results: A total of eleven donation after circulatory death heart transplants were performed. The mean donor age was 56.8 ± 4.8 years, with an average functional warm ischemic time (fWIT) of 49.5 ± 11.3 min. All hearts demonstrated preserved function pre-procurement and post-transplantation. No recipients required mechanical circulatory support (MCS) postoperatively, and the 30-day survival rate was 100%.

Conclusions: Heart transplantation with donation after circulatory death is a feasible and effective strategy to expand the donor pool, yielding short-term outcomes comparable to donation after brain death. Despite Italy's prolonged mandatory warm ischemic time, graft viability was maintained. Larger studies with extended follow-up are needed to confirm long-term efficacy and optimize patient selection criteria.

Keywords: DCD; ECMO; Functional warm ischemic time; Heart transplantation; TA-NRP.