Question of the Week 576
Author: Amy Babb, MD - Vanderbilt University Medical Center - Monroe Carell Jr. Children's Hospital at Vanderbilt
A 14-year-old boy on a Heartmate 3 is scheduled to receive an adult donor heart after donation after circulatory death (DCD). Normothermic Regional Perfusion (NRP) in DCD heart transplantation is best defined as which of the following?
EXPLANATION
Normothermic regional perfusion (NRP) is a technique used in donation after circulatory death (DCD) heart transplantation to preserve and assess the donor heart after death has been declared.1,2 In DCD donation, life-sustaining therapy is withdrawn and the patient progresses to irreversible circulatory arrest.1,2 After a legally mandated no-touch observation period which varies across institutions, sternotomy is performed and surgical steps are taken to ensure that blood flow to the brain cannot be restored.1,2 Extracorporeal membrane oxygenation (ECMO) is then initiated to re-establish warm, oxygenated circulation to the thoracic and abdominal organs, including the heart.1,2
A key feature of NRP is that the cerebral circulation is permanently excluded before ECMO begins, ensuring that the determination of death is not reversed.1,2 Unlike ex-situ perfusion systems, the heart remains inside the donor’s body during NRP.1,2 This allows the heart to recover metabolically and resume electrical and mechanical activity under controlled physiologic conditions.1,2 During this time, the transplant team can directly evaluate cardiac performance, including ventricular function, rhythm stability, coronary perfusion, and overall hemodynamic capability before the heart is removed for transplantation.1,2
Clinically and ethically, NRP aims to respect the determination of death while improving transplant outcomes.1-3 By restoring warm circulation and limiting warm ischemic injury, NRP allows the heart to recover before procurement and provides an opportunity to assess function.1,2 Early studies suggest that outcomes with DCD hearts using NRP are comparable to those achieved with hearts donated after brain death.2-4 As experience grows, NRP is increasingly being explored in both adult and pediatric heart transplantation as a strategy to expand the donor pool and reduce waitlist mortality.3,4
By restoring regional — but not global — circulation at normothermia, NRP differs fundamentally from whole-body reperfusion as the cerebral circulation is excluded.
REFERENCES
1. Urban M, Castleberry AW, Duncan KF, et al. Thoracoabdominal Normothermic Perfusion in Donation After Circulatory Death. Ann Thorac Surg. 2022;113(6):e473-e476. doi:10.1016/j.athoracsur.2021.08.075
2. Kharawala A, Nagraj S, Seo J, et al. Donation After Circulatory Death Heart Transplant: Current State and Future Directions. Circ Heart Fail. 2024;17(7):e011678. doi:10.1161/CIRCHEARTFAILURE.124.011678
3. Overbey DM, Kucera JA, Aykut B, et al. Pediatric heart transplant in donation after circulatory death using normothermic regional perfusion. J Thorac Cardiovasc Surg. 2025;170(4):1170-1175.e1. doi:10.1016/j.jtcvs.2025.06.015
4. Beckerman Z, Overbey D, Bryner BS, et al. Infant heart transplant following donation after circulatory death using normothermic regional perfusion and distant transport, first reported case in North America. JTCVS Tech. 2023;20:156-157. Published 2023 May 8. doi:10.1016/j.xjtc.2023.04.001