Lung transplantation after prolonged thoraco-abdominal normothermic regional perfusion in combined heart-lung procurement from controlled donation after circulatory death donors in Italy: Can lung graft withstand prolonged thoraco-abdominal normothermic regional perfusion?

The thoraco-abdominal normothermic regional perfusion (TA-NRP) procedure is an emerging strategy for heart recovery in controlled donation after circulatory death (cDCD). Its impact on lung graft recovery remains debated, especially regarding the duration of the TA-NRP procedure. This is particularly relevant in Italy, where the world’s longest mandatory stand-off period (20 minutes) leads to the prolonged TA-NRP procedure for heart assessment. This study evaluated the impact of the TA-NRP procedure on lung transplant outcomes in a nationwide experience. We analyzed all cDCD donations between June 2023 and June 2025 where both heart and lungs were considered for recovery. The TA-NRP procedure was established through the femoral vessels, with left atrial or pulmonary artery venting. During the study period, 24 cDCD donors were evaluated for combined heart-lung procurement. Sixteen lungs were successfully recovered and bilaterally transplanted into recipients (median age, 54 years). Median functional warm ischemia and asystolic times were 36 and 25 minutes, respectively. The TA-NRP procedure had a median duration of 125 minutes. Twelve recipients underwent direct transplantation, whereas 4 required ex vivo lung perfusion. Intensive care unit stay averaged 6 days, with a 12.5% primary graft dysfunction 3 rate at 72 hours. In-hospital mortality was 6.2%; 2 patients (12.5%) died from infections postdischarge. Our findings suggest that the prolonged TA-NRP procedure does not compromise short- or medium-term lung transplant outcomes.