Overcoming lung challenges in TA-NRP assisted heart recovery in donation after the circulatory determination of death

Abstract

Thoraco-abdominal normothermic regional perfusion (TA-NRP), utilizing Extra Corporeal Membrane Oxygenation (ECMO) devices, has emerged as an effective strategy for heart recovery in donors declared dead by circulatory criteria (DCDD). After death declaration, TA-NRP restores heart activity by reperfusing the arrested heart with oxygenated blood at normothermia. Mechanical ventilation resumption in the donor enables weaning from ECMO and restores systemic circulation and oxygenation using the donor’s heart and lungs. However, if pre-existing conditions prevent the donor’s lungs from oxygenating blood post-cardiac activity restoration, weaning from veno-arterial ECMO may lead to systemic hypoxia, jeopardizing the restored cardiac function. Anticipating this scenario may guide planning a split ECMO circuit to facilitate earlier and more effective recovery of donor heart function post-ECMO weaning. This manuscript describes three cases of DCDD donors with hypoxic respiratory failure undergoing TA-NRP for heart recovery. By establishing a bridge in the arterial portion of the circuit, clamped out after weaning from veno-arterial ECMO, donor heart function was assessed exclusively with veno-venous ECMO support, leading to successful heart transplantation.