The Time is Upon Us-The Beginning of the End of Donor Heart Reanimation In Donation After Circulatory Death...

Donation after circulatory death (DCD) heart transplantation has re-emerged as a transformative strategy to expand the donor pool after decades of dormancy. Historically, donor heart reanimation, either in situ or on ex situ perfusion platforms, has been considered essential to assess allograft viability following warm ischemic injury. Techniques such as thoracoabdominal normothermic regional perfusion (TA-NRP) and direct procurement and perfusion (DPP) have enabled contemporary DCD heart transplantation, but are limited by ethical concerns, high costs, technical complexity, donor discard rates, and restricted global applicability. Recent advances in non-reanimation-based preservation strategies, including hypothermic oxygenated machine perfusion (HOPE) and rapid recovery with extended ultra-oxygenated preservation (REUP), challenge this long-standing paradigm. Early clinical experience with both platforms demonstrates excellent short-term outcomes, no reported donor discard, and successful transplantation across extended ischemic times and diverse donor and recipient profiles without the need for pre-implant functional assessment. Importantly, these approaches avoid ethical concerns related to post-mortem reperfusion and are substantially less costly and more scalable than existing reanimation-based techniques. Emerging pediatric experience further underscores the potential impact of reanimation-less strategies, where technical, ethical, and logistical barriers have historically limited DCD heart transplantation. Collectively, these data call into question the necessity of donor heart reanimation. This perspective argues that the field of heart transplantation is undergoing a fundamental paradigm shift. As outcomes with non-reanimated DCD hearts continue to match or exceed those achieved with traditional approaches, donor heart reanimation may no longer represent the best practice.