Expanding our imagination with reanimation.

Orthotopic heart transplant remains the gold standard for the treatment of end‐stage heart failure. A major barrier to its utilization in all patients is a scarcity of candidates for organ donation. Historically, organs were only procured from donation after brain death (DBD), although its expansion in recent years has moved to donation after circulatory death (DCD). Following a variable “no touch” period after circulatory death, procurement teams race to salvage these higher‐risk organs for transplant. A significant concern with this donor pool is the warm ischemic time the organs face and their resultant increase in ischemia‐ reperfusion injury, leading to questionable graft function following transplant. Thoracoabdominal normothermic regional perfusion (TANRP) with extracorporeal membrane oxygenation (ECMO) devices has become a newer method of “reanimation” following circulatory death. The chest is opened, the head vessels clamped to ensure no possibility of circulation to the brain, and the patient is cannulated for venoarterial ECMO to restore perfusion to the thoracoabdominal organs. The arrested heart begins to beat again. This allows the heart team to inspect the beating heart and ensure it is appropriate for transplantation. The organ can then be procured and placed in cold storage if the team is satisfied. Early experiences in the United States and abroad have shown favorable outcomes for cardiac DCD compared to DBD, with cold ischemia times approaching 3 h. Ruiz et al. present a fascinating case of cardiac DCD utilizing TANRP and ECMO with a cold ischemia time of 201 min. In transplant, time is always of the essence and shorter ischemia times have been shown to lead to better outcomes. This comes under special consideration when warm ischemia is introduced into the picture, which can potentiate cardiac myocyte damage and function. Utilization of this technique for cardiac DCD not only helps to pick out favorable hearts, it also resets the ischemia clock allowing for cold storage from a favorable setpoint. Importantly, this technique expands the donor pool in a safe way without compromising graft quality. When addressing the organ shortage, it is imperative to not settle for suboptimal. This case demonstrates safety with 11min of functional warm ischemia time and over 3 h of cold ischemia with a favorable short‐ term outcome in their transplant recipient. The extent of allowable cold ischemia following cardiac DCD remains unknown, although this study reassures the beneficial effects of TANRP. This knowledge may help other surgeons push the time and distance boundary in DCD. However, more data utilizing this technique in cardiac DCD are required before we are able to make comprehensive recommendations on its use. We congratulate the authors on sharing their work and steadfast commitment to advancing the field of transplantation.