Thoracoabdominal normothermic regional perfusion in donation after circulatory death: variation in practice and the need for shared standards, transparency, and ethical safeguards

Introduction

Wang and colleagues provide a clear, rigorous, and timely video and instructive supplemental detailing current international approaches to thoraco-abdominal normothermic regional perfusion (TA-NRP) (1). Their comparative description of the Colorado, Spanish, and United Kingdom (UK) experiences illustrates not only the technical considerations in TA-NRP, but also highlights the diversity of ethical, regulatory, and logistical frameworks that shapes technique. This work arrives at a pivotal moment, as TA-NRP continues to gain global traction in donation after circulatory death (DCD) pathways and as clinicians, policymakers, and donor communities face questions of safety, consistency, and public trust. The authors’ contribution meaningfully advances this discussion by offering a detailed and transparent justification of strategies in use across three major transplantation regions.

The procedural descriptions demonstrate an intimate understanding of the technical imperatives of TA-NRP—rapid restoration of regional perfusion, prevention of cerebral reperfusion, and controlled support of thoracic and abdominal organ recovery. The manuscript, however, does more than simply outline technique. It introduces why these differences exist: the varying legal allowances for pre-mortem intervention, differing national definitions of death, variations in ethical oversight, and institutional experience with NRP and perfusion devices. The authors generate the opportunity for thoughtful reflection on a central challenge facing the field—how to harmonize global practice in a way that preserves donor dignity, permits local adaptation, and accelerates safe, equitable expansion of TA-NRP.

The imperative for established robust and scalable protocols

One of the more compelling themes emerging from the authors’ comparison is the need for procedural clarity and standardization. Even among experienced programs, differences persist in how and when cannulation occurs, how arch vessels are controlled, and how cerebral reperfusion is prevented and verified. Such variation is not inherently problematic—but rather reflects real differences in regulatory constraints or institutional resources. It may, however complicate training, comparative research, and public communication. The challenge, therefore, is to establish standardized principles rather than rigid uniformity. In keeping with ongoing efforts toward harmonisation, recent US-based guidance from the Organ Procurement and Transplantation Network (OPTN) and the Health Resources and Services Administration (HRSA) (November 2025) has reinforced standardised approaches to arch vessel management in TA-NRP to ensure reliable cerebral exclusion and procedural transparency (2).

Examples of core principles that could be considered beneficial for international alignment include:

• Documentation of how cerebral circulation is excluded, whether through clamping, division, or open-ended drainage;
• Standardized definitions of functional warm ischemia and procedural milestones;
• Unified expectations for heparinization timing, circuit priming, and venting strategies;
• Shared thresholds for terminating NRP based on pre-established clinical and biochemical criteria.

At the same time, flexibility must remain for programs operating under different ethical or legal restrictions. Spain’s allowance for pre‑mortem cannulation and the UK’s prior mandate for three-vessel cannulation under negative pressure all represent adaptations shaped by local oversight rather than differences in clinical intent. The authors are right to present these differences without judgment; their work underscores that TA-NRP is best supported when foundational ethical principles are upheld while operational specifics remain locally responsive.

Building trust as a central ethical requirement

Perhaps the greatest determinant of TA-NRP’s future success is trust. This is not only trust between clinicians, but also among donor families, policymakers, and the broader public. Concerns about inadvertent cerebral perfusion remain at the forefront of ethical debate, even when theoretical risk is low and empirical evidence remains reassuring. The authors’ frank discussion of vessel ligation, division, and drainage strategies is therefore particularly valuable.

Ethical stewardship in TA-NRP requires:

• Transparent communication—detailing how cerebral blood flow is both prevented and how those measures are verified;
• Consistent procedural documentation—including records of cerebral exclusion;
• Interdisciplinary review—involving ethicists, intensivists, and donor family advocates;
• Public clarity—ensuring communities understand the purpose, limitations, and safeguards of the technique.

By documenting how different jurisdictions navigate these safeguards, the authors contribute to an essential global conversation. While no single technique will satisfy all regulatory bodies, the field must work collectively to define the minimum acceptable safeguards needed to ensure that TA-NRP remains ethically and socially legitimate.

The importance of technical excellence across organ systems

A further strength of the authors’ manuscript is its recognition that TA-NRP is not solely a cardiac procurement strategy. Properly implemented, it has profound benefits for abdominal organ recovery as well. The description of right atrial cannulation to relieve distension, pulmonary artery venting to manage afterload, and careful management of the aortic cannula all speak to the delicate physiologic balance required to support all organs being considered for transplantation. Good technique ensures:

• Re-animation of the heart under controlled, normothermic conditions, allowing real‑time functional assessment;
• Superior abdominal organ outcomes—including (I) increased organ utilization and reduced ischemic cholangiopathy post liver transplantation (3,4); and (II) decreased delayed graft function and improved long-term graft function post kidney transplantation (5,6).

As organ demand continues to exceed supply, TA-NRP represents a crucial opportunity to expand the DCD donor pool and the utilization of more organs from these donors. The authors successfully emphasize that its benefits extend beyond thoracic transplantation and that careful cannulation strategy is pivotal for achieving multi-organ optimization.

The role for common data, metrics and training pathways

To strengthen the field further, the discussion can be expanded to emphasize the need for shared outcome reporting and standardized metrics. Given the heterogeneity of TA-NRP implementation worldwide, unified data collection (including perfusion parameters, biochemical markers, cerebral exclusion evidence, and post‑implant outcomes) would enhance comparative evaluation and guide iterative improvements.

In a field where time is of critical importance for post-transplant outcomes, and physiologic derangements and organ injury can worsen rapidly, team and procedural familiarity is invariably beneficial. Equally important is the development of structured interdisciplinary training, including:

• Simulation-based rehearsals for procurement teams;
• Perfusionist collaboration on circuit management;
• Standardized competency pathways for surgeons beginning TA-NRP practice;
• Cross-institution exchange programs to harmonize experience levels.

Equity and global accessibility

An additional consideration is the potential for TA-NRP to widen disparities between high-resource and low‑resource regions. The equipment and expertise required for TA-NRP are significant, raising concerns that its benefits may concentrate in well-funded health systems. As adoption expands, inclusivity must remain a core ethical commitment. A globally responsible approach to TA-NRP must therefore prioritize:

• Scalable protocols suitable for variable-resource environments;
• International educational initiatives;
• Knowledge-sharing frameworks that allow newer programs to learn from high-volume centers.

Future directions

Looking ahead, several areas stand out as potential areas for research and consensus-building. Firstly, research that further confirms the absence of cerebral perfusion during TA-NRP has the potential to foster community trust and facilitate broader consensus. Secondly, studies that not only compare, but also explore how TA-NRP and other ex-situ perfusion technologies can complement one other, will prove essential to enhancing organ specific outcomes, while simultaneously refining both the indications for these technologies and the optimal resource allocation. Finally, the field will continue to benefit immensely from the creation of international consensus guidelines, developed collaboratively and mindful of local contexts and cultural differences, will be vital in establishing minimum ethical, technical, and monitoring standards for TA-NRP worldwide. These initiatives will help harmonise practice globally while respecting regional diversity.

Conclusions

This comparative analysis of approaches in the USA, Spain, and the UK highlights both the promise of the technique and the challenges that remain. As adoption continues to grow, the transplant community must strive for shared standards, transparent safeguards, and disciplined technique, while embracing innovation and collaboration across borders. The authors’ thoughtful contribution advances these goals and adds important clarity at a moment of rapid evolution in organ donation and transplantation. Their work strengthens not only the scientific understanding of TA-NRP but the ethical foundation upon which its future development depends.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery. The article has undergone external peer review.

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0016/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0016/coif). A.W. reports serving as the Medical Director of Regional Perfusion Services, LLC. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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2. Organ Procurement and Transplantation Network (OPTN); Health Resources and Services Administration (HRSA). Letter to OPTN members: normothermic regional perfusion safety notice. 2025. Available online: https://www.hrsa.gov/sites/default/files/hrsa/optn/letter-to-optn-nrp-safety-notice-251121.pdf (accessed 15 May 2026).
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