Early results of beating-heart transplantation after thoraco-abdominal normothermic regional perfusion in controlled donation after circulatory death donors.

BACKGROUND

Heart transplantation from controlled donation after circulatory death expands the donor pool but exposes the graft to substantial ischemic injury. In Italy, the mandatory 20-minute no-touch period further prolongs warm ischemia. Thoraco-abdominal normothermic regional perfusion allows in situ graft recovery and assessment, while beating-heart implantation may avoid an additional ischemic injury.

METHODS

These case series included six consecutive recipients transplanted at two Italian centers between October 2025 and May 2026. All donor hearts underwent thoraco-abdominal normothermic regional perfusion, followed by beating-heart procurement and implantation with continuous normothermic coronary perfusion. Donor, procedural, and early postoperative outcomes were analyzed descriptively.

RESULTS

Median donor age was 61.5 years. Median functional warm ischemic time and total warm ischemic time were 38.5 and 46 min, respectively. Thoraco-abdominal normothermic regional perfusion restored satisfactory biventricular function in all donors, allowing successful graft assessment. Beating-heart procurement and implantation were completed in all recipients. Thirty-day patient and graft survival were 100%, and no recipient developed severe primary graft dysfunction requiring mechanical circulatory support within the first 72 h after transplantation. All recipients had preserved biventricular function at discharge.

CONCLUSIONS

Heart transplantation after controlled donation after circulatory death using thoraco-abdominal normothermic regional perfusion and beating-heart implantation is feasible despite prolonged warm ischemic times mandated by Italian legislation. This ischemia-sparing strategy enables reliable graft assessment, avoids routine ex situ machine perfusion, and was associated with excellent early graft function and survival, supporting further evaluation in larger studies.