Ex Situ Heart Perfusion in Extended Criteria and Donation After Circulatory Death Heart Transplantation

The persistent shortage of donor hearts has driven increased utilization of extended criteria donors and donation after circulatory death (DCD) allografts. Ex situ heart perfusion (EHP) technologies have emerged as a key strategy to expand the donor pool by reducing ischemic injury, enabling functional assessment, and extending preservation times. This narrative review examines current EHP systems and their impact on heart transplantation. We summarize the technical principles of normothermic pulsatile perfusion and hypothermic non-pulsatile perfusion, cannulation strategies, perfusion parameters, and viability assessment. Contemporary clinical evidence from prospective trials and multicenter registries demonstrates that EHP increases the utilization of extended-criteria donors and DCD hearts, prolongs permissible ex situ times, expands geographic reach, and yields early- and mid-term outcomes comparable to or superior to traditional static cold storage. Particular benefits are observed in DCD transplantation when EHP may be combined with thoracoabdominal normothermic regional perfusion. Important limitations include high device and personnel costs, logistical complexity, lack of long-term data, uncertainty regarding safe maximum ex situ duration, and ethical/regulatory variations in DCD protocols. Despite these barriers, EHP represents a transformative advance in heart transplantation, with growing adoption worldwide. Anesthesiologists are increasingly involved in organ procurements with thoracoabdominal normothermic regional perfusion and heart transplantation with allografts preserved via an increasing range of pathways, each with its own potential clinical implications.