Donation after circulatory death (DCD) without thoracoabdominal normothermic regional perfusion or commercial ex situ perfusion systems is possible using a novel technique – rapid recovery with extended ultraoxygenated preservation (REUP) – according to a brief report published July 16 in NEJM.

"Our technique involves the use of a flush circuit to oxygenate two liters of a cold preservation solution consisting of packed red cells, del Nido cardioplegia, and other additives," write Aaron M. Williams, MD, et al. "The solution is administered at a mean aortic-root pressure of 80 mmHg over a period of approximately 10 to 12 minutes." They highlight three cases in which the REUP recovery method was successfully used.

They note numerous highlights from their experimentation, including that findings from their case reports indicate "there is a window of reversibility of the cellular-death process that commences after circulatory death." In addition, they suggest that thoracoabdominal normothermic regional perfusion or ex situ perfusion systems used to reanimate the heart may be unnecessary for DCD heart transplantation.

Acknowledging the ethical concerns involved in normothermic regional perfusion, an approach that has had limited uptake in the U.S., the authors present how their technique circumvents these challenges. "Our technique flushes oxygenated preservation solution to the donor heart only, without reanimation of the heart and without systemic or brain perfusion, and does not require clamping of the aortic-arch vessels," they write.

An additional brief report published July 16 in NEJM presents a new technique to perform DCD heart recovery in pediatric patients: on-table reanimation.

John A. Kucera, MD, et al., describe the setup of an on-table reanimation circuit and present a case study involving DCD procurement from a 1-month-old donor. Following on-table reanimation, the donor heart was successfully transplanted into a 3-month-old recipient. Follow up three months post operation revealed an echocardiogram displaying "normal cardiac function" with no evidence of "primary graft dysfunction or acute cellular or antibody-mediated rejection."

Although this innovative technique was developed to avert the ethical concerns tied to DCD with normothermic regional perfusion, Kucera and colleagues highlight that this method does not skirt all ethical challenges tied to the approach, noting that "reservations regarding permanency of death should be acknowledged in the context of restarting a donor heart."

"This technique is not meant to be a substitute if normothermic regional perfusion were allowed but is instead meant to provide an alternative at centers where ethical constraints limit the performance of normothermic regional perfusion in children," they write.