Increasing the acceptance of thoracoabdominal normothermic regional perfusion in donation after circulatory determination of death heart donation: A case for collaborative donor research

Donation after circulatory determination of death transplantation offers an effective and safe method of increasing the number of heart transplants performed. Donation after circulatory determination of death heart is ischemic at the time of recovery, 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. There is a growing body of evidence that taNRP is associated with better utilization of thoracic and abdominal organs from the donor and with superior recipient outcomes. taNRP offers a cheaper alternative to organ recovery than direct procurement and preservation. In addition, taNRP can also be used in pediatric transplantation. However, there are still concerns regarding the ethical acceptability of taNRP. These concerns center 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.