Beating Heart Transplantation May Facilitate Liberal Use of Extended Criteria Donors

OBJECTIVE: Extended criteria donor (ECD) hearts are particularly vulnerable to ischemia-reperfusion injury and thus more prone to primary graft dysfunction. We test the hypothesis that by minimizing ischemia-reperfusion and cooling-rewarming injury, ex-vivo machine perfusion and beating heart transplant (BHT) can allow liberal and safer use of ECD hearts. METHODS: Between 2023 and 2025, 130 BHTs (109, isolated, 21 combined with kidney and/or liver) were performed in our center. These were retrospectively compared to 138 historical and concurrent transplants performed using controlled cold storage (CCS) between 2020 and 2025. ECD was defined based on the EXPAND trial criteria. RESULTS: Among the BHT group, 64% (83/130) utilized ECD hearts, compared to 37% (51/138) in the CCS group (P<0.001). Despite a high predominance of ECD donors in the BHT cohort the one-year survival was not inferior to the CCS cohort (93%±4.4% vs. 81.1%±6.5%, p=0.01). Among ECD donors, LVH was more common in BHT donors (30% vs. 12%, p=0.03), median ECD donor age was higher (46 [38-50] vs. 31 [25-40] years, p<0.001), and median procurement distance was five times longer (409 vs 74 miles, p<0.001) with BHT compared to CCS. Specifically for BHT ECD recipients, severe LV-PGD at 24 hours occurred in 1.2% (1/83), and one-year survival was 92.7%±5.6%. CONCLUSION: Beating heart implantation using continuous normothermic perfusion may allow expanded use of ECD hearts, including from older and distant donors, without compromising early outcomes.