Repairing cardiac allografts on ex situ perfusion devices

The persistent scarcity of donor allografts for transplantation has led to the acceptance of donors deemed ‘marginal’, due to factors such as older age, or indeed donor pathway. Ex situ organ perfusion or machine perfusion has evolved in the last decade as the primary technique utilised to facilitate the safe transplantation of such organs, traditionally often associated with higher rates of primary graft dysfunction, and subsequently, poor recipient outcomes. As well as having been demonstrated to permit the use of marginal brain dead donors with non-inferior outcomes, machine perfusion has also played a critical role in the development of heart transplant programs utilising donation after circulatory death donors. This represents a rapidly evolving area in heart transplantation, with over a decade of rigorous basic science research now translating into an increased quantity and quality of donor hearts for transplantation. Regardless of where future advances are made, current clinical experience and outcomes with marginal brain dead and donation after circulatory death donors has established ex situ perfusion and resuscitation of cardiac allografts as an invaluable tool in heart transplantation.