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.