BY THE OPTIMIST DAILY EDITORIAL TEAM

In January 2020, surgeons at NYU Langone Health performed a groundbreaking procedure that restarted a donor’s heart after it had stopped beating. The heart was then transplanted into a patient in need. While effective, the method sparked significant ethical debate about the definition of death. Now, two newly published studies in The New England Journal of Medicine introduce alternative strategies that may avoid such controversies while preserving donor hearts more effectively.

“These are all very exciting innovations,” said Paul Tang, a cardiovascular and transplant surgeon at the Mayo Clinic not involved in either study. “They’ve bypassed a lot of the ethical concerns.”

The challenge of circulatory death

Traditionally, donor hearts come from individuals who have been declared brain dead but whose bodies are still supported by machines to keep organs oxygenated. In more recent approaches, surgeons retrieve hearts from donors who die after circulatory arrest, known as donation after circulatory death (DCD). But circulation loss, even briefly, deprives the heart of oxygen and can cause irreversible damage.

To assess and preserve these vulnerable hearts, transplant teams have typically relied on one of two strategies. The first involves removing the heart and connecting it to a costly perfusion machine that pumps warm, oxygenated blood. While effective, these systems are expensive, labor-intensive, and unavailable for pediatric use.

The second option, normothermic regional perfusion (NRP), circulates blood through the donor’s body using standard hospital equipment after the heart has stopped. This reanimation allows doctors to observe heart function directly, and it’s more affordable and adaptable for pediatric donors. However, NRP has raised ethical red flags: opponents argue it conflicts with the legal definition of death, and some worry about residual blood flow to the brain despite clamping vessels.

In 2021, the American College of Physicians issued a formal statement of concern, prompting some hospitals and countries to ban NRP entirely.

Innovation for infant hearts

To navigate these concerns in pediatric care, a team led by Joseph Turek at Duke University developed a method to reanimate infant hearts outside the body. Using a simplified, lower-cost perfusion circuit, surgeons pump oxygenated blood into the heart through a small catheter, allowing it to “wake up” while surgeons observe its function.

“We’re seeing the coronary arteries fill. We’re seeing the tissues pink,” Turek explained.

In one early case, Turek’s team successfully transplanted a heart from a 1-month-old into a 3-month-old. The recipient was still healthy three months post-surgery. Turek estimates this approach could expand the pediatric donor pool by up to 20 percent.

Cooling the heart to save it

At Vanderbilt University Medical Center, cardiac surgeon Aaron Williams and colleagues tested a different approach: preserving the heart without restarting it at all. Their method, dubbed recovery with extended ultraoxygenated preservation (REUP), involves injecting a cold, oxygen-rich solution into the aorta shortly after circulatory death. This cocktail revives the tissue’s oxygen levels and clears out harmful byproducts without triggering a heartbeat.

“We’re not reanimating the heart,” Williams emphasized. “We’re resuscitating it.”

The team successfully used REUP in three adult transplants. All recipients showed strong recovery and no signs of organ rejection six months later. According to study co-author John Trahanas, the process is low-cost, requires minimal staffing, and could be used in smaller or resource-limited hospitals.

Ethics, innovation, and what comes next

REUP challenges the standard belief that transplant teams must restart a heart and assess its beating function before use. While promising, it does carry a risk: surgeons can’t directly observe heart performance before transplant, which may be problematic in older donors or in cases with long time lapses between life support withdrawal and death.

Despite those tradeoffs, experts see potential. “It’s a very promising paper,” said Nader Moazami, who led the 2020 NRP transplant at NYU Langone. But Moazami and others note that NRP, for all its controversy, allows doctors to preserve multiple organs at once, which is a key advantage REUP doesn’t offer.

Brendan Parent, a bioethicist at NYU Grossman School of Medicine, praised both REUP and the new pediatric perfusion method but stressed the need for consensus. “What we need to do is come to some sort of consensus around the ethical way to proceed with NRP,” he said.

That consensus may depend on more research into whether any blood flows to the brain during NRP. But as Moazami noted, the debate should never lose sight of the lives at stake: “People are trying very hard to save as many lives as they can.”