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What are the barriers to wider use of organ perfusion?

Simple diagram with dotted line framing red circle with icon of human heart to represent organ perfusion


UNOS Chief Medical Officer David Klassen, M.D., discusses perfusion-driven advances and remaining challenges

Normothermic perfusion continues to show promise as an innovation that will help increase the number of donor organs available for transplant. With perfusion, circulation and normal body temperature and function are maintained for the organ, making it possible both to evaluate the organ and potentially to limit the impact of ischemic time. However, cost, technology and training considerations remain barriers to widespread implementation. UNOS Chief Medical Officer Dr. David Klassen discusses recent developments in the field.
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Explore issues in normothermic perfusion with a curated reading list

Q. Where is perfusion having the most impact right now in organ transplantation?

We’re seeing a steady increase in the number of organs being perfused. In 2022, more than 1,100 transplanted donor livers, hearts and lungs were perfused. Between 2018 and 2022, there was an almost five-fold increase in perfused livers transplanted, from fewer than 100 to nearly 500.

Perhaps the most important recent development is perfusion for DCD (donation after circulatory death) heart transplantation. Because the heart is particularly vulnerable to warm ischemic injury, increasing the number of successful DCD heart transplants was really dependent on perfusion technologies. A third of all donors are DCD donors, and potentially a significant number could be heart donors; one study estimated that widespread adoption of DCD heart transplant could lead to 300 more adult heart transplants annually.  UNOS data show that the number of DCD hearts perfused and transplanted has gone from 0 in 2018 to 199 in 2022.

photo Dr. David Klassen, UNOS Chief Medical Officer

“Perhaps the most important recent development is perfusion for DCD (donation after circulatory death) heart transplantation.”

David Klassen, M.D., Chief Medical Officer

Q. Are there other significant new developments?

In addition to ex-vivo machine perfusion, normothermic regional perfusion (NRP) for recovery of organs from DCD donors is now spreading fairly widely, and is also helping to increase the number of DCD hearts available for transplant. (See Normothermic Regional Perfusion: A reading list.) With NRP, cardiopulmonary bypass or ECMO is used to restore circulation and enable perfusion of DCD organs prior to recovery. Because these technologies are already in use in most ICUs, there is no new technology to acquire or learn to use, as there is with ex-vivo machines. Also with NRP, separate perfusion devices for each organ aren’t needed, as abdominal and thoracic organs can be perfused before recovery with this process.

Q. What barriers remain to greater use of perfusion?

At the present time cost remains the most significant limiting factor for either type of perfusion. It’s expensive, and questions have yet to be resolved about when it is most appropriate to use perfusion,  who pays for it, and how those costs are reimbursed.  Whether cost will limit the use of perfusion to larger and better-resourced transplant centers or OPOs remains to be seen.

Implementation of these technologies is also logistically complex.   It takes time and effort for new technologies and procedures like these to be widely incorporated.

Finally, more data are needed to firmly determine whether perfusion leads to better patient outcomes. Research so far indicates generally equal outcomes when compared with non-perfused organs.  Despite these questions perfusion is enabling increased use of expanded criteria and DCD organs, including those that previously might not have been considered viable for transplant.

A reading list

Understanding Normothermic Regional Perfusion (NRP)

Rather than perfusing donor organs by machine after recovery (“ex-vivo” perfusion), NRP uses extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass technology to restore circulation and perfuse DCD donor organs prior to recovery from the deceased donor. The advantages of NRP include the potential to reduce warm ischemia time for DCD donor organs and the ability to assess DCD hearts prior to recovery.

However, NRP is technically complex and requires rapid, coordinated execution by a skilled team. To ensure success with the procedure, the recovery team may need to bring all the necessary equipment and supplies, as well as its own perfusionists, which can add to the cost and other considerations of procurement.

In addition, questions have been raised even within the medical community about the ethics of a procedure that restores circulation in a deceased donor as well as about the transparency necessary for true informed consent from donor families.

This reading list provides an overview of NRP as well as discussions and recent perfusion news coverage.

Oct. 2022 | American Society of Anesthesiologists: “Statement on Controlled Organ Donation After Circulatory Death”

April 2021 | The American College of Physicians: “The American College of Physicians says organ procurement method raises significant ethical concerns”

Feb. 2020 | The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine: “Why DCD donors are dead” An ethical and philosophical analysis of NRP and DCD transplant.

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Another record year for heart transplants: Steep increases seen in DCD transplants in 2022

in focus

A 68% increase in DCD heart transplants was part of a record-setting 2022

68% increase in DCD heart transplants in 2022

The 11th straight year of increases in heart transplants coincides with advancements in organ perfusion technology and DCD recovery practices.

In 2022, 42,888 organ transplants were performed in the United States, an increase of 3.7 percent over 2021 and a new annual overall record.*

While new records were also set for liver, kidney and lung transplants, heart transplants in particular experienced a steep increase, from both donation after brain death (DBD) donors, as well as donation after circulatory death (DCD) donors.

Heart transplants increased overall by 21.5 percent (4,169 in 2022)

DBD heart transplants increased 4.6 percent (3,822 in 2022)

DCD heart transplants increased 68 percent (347 in 2022)

Advances in technology and donor recovery practices contributing to increases

Rapidly-evolving perfusion technology is allowing more DCD hearts to be transplanted. Perfusion allows organs to remain viable for longer periods outside the body; this is important for organs such as hearts and lungs, which have shorter windows of time when compared to kidneys. 2022 saw a 95 percent increase in transplants of machine-perfused hearts.

Coinciding with these advances in technology, increasing recovery of DCD donors has been a key area of focus for the nation’s 56 organ procurement organizations (OPOs) for a number of years. A recent UNOS-led collaborative project helped OPOs share effective practices related to recovering DCD donors to increase transplant. Over the course of the national project, 75 percent of OPOs participated in one or both of the two cohorts, contributing to the overall increases in DCD donors recovered and DCD organs transplanted. A subsequent collaborative project is currently focused on increasing transplantation of DCD lungs, and more than 40 percent of the nation’s lung transplant programs are participating.  

A report from the National Academies of Sciences, Engineering and Medicine (NASEM) recommends taking collaborative improvement approaches as well as embracing innovative technologies to maximize organ use, in particular use of DCD organs.  

February is American Heart Month. Get resources, fact sheets and other information on the National Institutes of Health website.  

*According to the most recent data from the Organ Procurement and Transplantation Network (accessed Feb. 13, 2023)

In focus

February is American Heart Month

7 years of HOPE

7 years of HOPE

Implemented in 2015 , the HIV Organ Policy Equity (HOPE) Act has given more than 350 living with HIV an opportunity to receive a lifesaving transplant from an HIV-positive donor.

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UNOS CEO Brian Shepard to leave organization after a decade of service

United Network for Organ Sharing (UNOS) today announced that CEO Brian Shepard will depart the organization at the end of September, following the completion of his contract. Shepard’s 10-year tenure as UNOS CEO was marked by groundbreaking progress in the U.S. organ donation and transplantation system.

Maureen McBride, Ph.D., UNOS’ chief operating officer, will assume the role of interim CEO beginning Oct. 1 while UNOS conducts a national search for Shepard’s successor. McBride has been with the organization since 1995. She served as director of research until 2014, when she accepted her current role as COO.

Brian Shepard, CEO, United Network for Organ Sharing

A commitment to improving the system

During his tenure, Shepard presided over the adoption of innovative policies, lifesaving improvements and record increases in both organ donation and transplant, including 2021, when the national system conducted more than 41,000 transplants in a single year, a global record. These and other advancements have positioned UNOS to drive the next phase of system progress, from increasing equity in transplant to adopting cutting-edge technologies, to collaborative improvement, further strengthening the nation’s high performing system and saving more lives.

“As UNOS CEO, Brian was a constant and courageous advocate for increasing equity in our national donation and transplantation system,” said Jerry McCauley, M.D., vice-president of the UNOS Board of Directors and incoming president. “His leadership has resulted in marked improvements in access to transplant for patients of color and those who have been historically marginalized. I am proud to have worked alongside Brian as a member of the UNOS board and am excited to build upon the foundation he has laid to further advance our mission and save even more lives.”

“UNOS is the engine that powers the U.S. donation and transplant system, and we are so lucky to have had Brian Shepard in the driver’s seat for the past decade,” said Matthew Cooper, M.D., president of the UNOS Board of Directors. “During such a pivotal time in our community, Brian took UNOS to the next level, driving accomplishments and championing the work of so many. His is a legacy to be celebrated.”

Prioritizing patients, equity and innovation

Under Shepard’s leadership, UNOS undertook a series of efforts to increase equitable access to transplant, including adopting a new way to distribute donor organs that emphasizes patient need. These new polices have resulted in greater access for the sickest patients.

“These changes to organ distribution weren’t easy or always popular, and it was so important to have Brian centering these discussions,” said David Mulligan, M.D., immediate past president of the UNOS board. “Now that these policies are in place, we can see the positive impact they’re having on patients and families across the country.”

Additionally, Shepard was instrumental in the development of UNOS Labs, an innovation center dedicated to fostering new ideas and encouraging experimentation. Since its founding, UNOS Labs has developed transplant-focused predictive analytics to help doctors decide whether to accept an organ offer for their patient, a GPS tracker for organ shipments, an offer simulator to conduct behavioral science research to improve organ matching, and a high-quality medical image sharing platform.

“The UNOS team is the most incredibly talented and dedicated team I’ve ever had the honor of being a part of,” said Shepard. “I’ve always viewed my job as making their job easier; removing obstacles and watching them run. I’m so proud of what they’ve accomplished and of all of the ongoing efforts that will further improve donation and transplant in the U.S.”

A vision for the future of organ allocation

Over the last several years, Shepard has helped put into place a new allocation policy, called continuous distribution. This innovative approach dissolves rigid boundaries, and is structured so that no single attribute determines whether or not a patient receives a transplant. Importantly, continuous distribution is also designed to allow for more patient engagement in the decision-making process.

“As a three-decade heart transplant survivor who strongly advocates increased involvement for transplant patients in the policy development process, continuous distribution is a game changer,” said Jim Gleason, president of Transplant Recipients International Organization (TRIO). Gleason has engaged with UNOS for more than 25 years and is a two-term former UNOS Board member. “This effort is not only going to help guide patients to the information they need in their transplant journey, it will also give them an active contributor seat at the decision-making table.”

A lasting legacy

“From policymaking to technology, from system-wide improvements to one-on-one interactions, Brian’s leadership has left an indelible mark on UNOS and the wider donation and transplant community,” said Sue Dunn, former CEO of Donor Alliance and a former UNOS board president. “But for me, to see his ongoing commitment to honoring selfless donors, their courageous families, and recognizing the often-thankless work of our OPOs – that is a legacy be proud of.”

“We’ve come such a long way in the last decade,” said Shepard. “While I am honored that the Board asked me to continue to serve as CEO, I felt it was the right time to take the next step. I have worked with so many amazing and dedicated people over the years who made it possible to accomplish all that I originally set out to do as UNOS CEO. Now, as we embark on a new chapter with even more exciting opportunities, I know the UNOS team and the donation and transplant community are in good hands, and I’m excited about the future.”

United Network for Organ Sharing (UNOS) is the mission-driven non-profit serving as the nation’s transplant system under contract with the federal government. We lead the network of transplant hospitals, organ procurement organizations, and thousands of volunteers who are dedicated to honoring the gifts of life entrusted to us and to making lifesaving transplants possible for patients in need. Working together, we leverage data and advances in science and technology to continuously strengthen the system, increase the number of organs recovered and the number of transplants performed, and ensure patients across the nation have equitable access to transplant.

For media inquiries, contact or (804) 782-4730.

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Ex Situ Perfusion of Hearts Donated After Euthanasia: A Promising Contribution to Heart Transplantation

Transplant Direct. 2021 Feb 22;7(3):e676. doi: 10.1097/TXD.0000000000001120. eCollection 2021 Mar.


Organ donation after euthanasia is performed in an increasing number of countries. In this donation after circulatory death procedure, it has not been possible to donate the heart. Recent literature, however, reports positive results of heart donation after circulatory death. Therefore, patients who donate organs following euthanasia might be suitable candidates for heart donation. We want to confirm this assumption by sharing the results of 2 cases of heart donation following euthanasia with ex situ subnormothermic heart preservation. Our aim is to raise awareness of the potential of heart donation following euthanasia for both clinical transplantation and research.

METHODS: The data of 2 consecutive heart donations following euthanasia were collected prospectively. Informed consent was obtained from the patients themselves for heart donation for research purposes. An acellular oxygenated subnormothermic machine perfusion strategy was used to preserve both donor hearts. Subsequently, the hearts were evaluated on a normothermic perfusion machine using a balloon in the left ventricle.

RESULTS: Heart donation following euthanasia was feasible without significant changes in existing retrieval protocols. Duration of machine perfusion preservation was 408 and 432 minutes, for heart 1 and 2, respectively. For heart 1, developed pressure (Pdev) was 119 mm Hg, maximal rate of pressure rise (dP/dtmax), and fall (dP/dtmin) were 1524 mm Hg/s and -1057 mm Hg/s, respectively. For heart 2, Pdev was 142 mm Hg, dP/dtmax was 1098 mm Hg/s, and dP/dtmin was -802 mm Hg/s.

CONCLUSIONS: Hearts donated following euthanasia are highly valuable for research purposes and can have sufficient quality to be transplanted. With the implementation of ex situ heart perfusion, patients who are to donate their organs following euthanasia should also be able to donate their hearts. The complex combination of euthanasia and heart donation is ethically sound and surgically feasible and can contribute to shortening the heart transplant waiting list.

PMID:34104712 | PMC:PMC8183709 | DOI:10.1097/TXD.0000000000001120

Commentary: Planes, trains, and automobiles-Effective use of prolonged ex vivo heart preservation

J Card Surg. 2021 Jul;36(7):2596-2597. doi: 10.1111/jocs.15520. Epub 2021 Mar 30.


Throughout the world, a shortage of donor organs has prompted development of unique strategies to expand the donor pool. Here, we review a report by Medressova and colleagues to the Journal of Cardiac Surgery detailing the 3-year follow-up of a patient who successfully underwent a heart transplant after 17 hours of ex-vivo preservation.

PMID:33783039 | PMC:PMC8187278 | DOI:10.1111/jocs.15520

Public comment open from Jan. 21 through Mar. 23 2021

The winter 2021 public comment cycle opens Jan. 21 and will close March 23. The Organ Procurement and Transplantation Network (OPTN) is offering six proposals, two requests for feedback, and one white paper for public comment.

Comments and replies will be published here on the OPTN website to promote transparency and trust in the national transplant system. Visitors also have the option to share their posted comments to social media.

We encourage patients, transplant candidates and recipients, living donors, donor families and transplant professionals to learn more about the proposals and provide their valuable feedback to help shape U.S. organ transplant policy.

Items available for public comment:

  • 2021-2024 OPTN Strategic Plan
  • Calculate Median MELD at Transplant around the Donor Hospital and Update Sorting within Liver Allocation
  • Clarify Multi-Organ Allocation Policy
  • Develop Measures for Primary Graft Dysfunction in Hearts
  • Modify the Deceased Donor Registration (DDR) Form
  • Require Notification of Human Leukocyte Antigen (HLA) Typing Changes
  • Revise General Considerations in Assessment for Transplant Candidacy
  • Update National Liver Review Board Guidance Documents and Policy Clarification
  • Update Transplant Program Key Personnel Training and Experience Requirements

Educational resources will be made available January 21 to provide multiple opportunities to learn more about the proposals.

All comments are reviewed and considered by the OPTN Board of Directors before they vote on the proposals to become policy. Learn more about the policy development process here.

Engage in public comment


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Saving lives together: Happy Holidays from the UNOS Organ Center

This holiday season, organ placement specialists are working around the clock in the UNOS Organ Center to help place lifesaving organs across the country. Here’s their holiday message for everyone touched by transplant. We wish you all a healthy and peaceful New Year!

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OPTN Board approves pediatric transplant program components, strategic planning, operational actions

Pediatric transplant program components

The Board of Directors of the Organ Procurement and Transplantation Network, at a virtual meeting held Dec. 7, approved pediatric components for 268 heart, kidney, liver, lung and pancreas transplant programs. Effective Dec. 8, any candidate younger than age 18 must be listed at one of these programs unless an exception is made for a very medically urgent heart or liver candidate. The searchable member directory on the OPTN website will display programs with a pediatric component.

“This is a key milestone in promoting the safety and efficiency of transplantation for children in need of a transplant,” said David Mulligan, M.D., president of the board. “The requirements were developed carefully to ensure that these programs have highly trained and experienced clinical staff and appropriate facilities to care for the specific needs of pediatric candidates and recipients. The application and review process took place in a staged fashion to allow programs interested in applying to take any needed steps to ensure they would qualify.”

Strategic planning

The board heard an overview of ongoing development of the OPTN Strategic Plan for 2021 through 2024. The OPTN Executive Committee will circulate a draft plan for public comment in January 2021, and a proposed final plan will be presented for board action in June 2021. As currently envisioned, there are four overall strategic goals:

  • Increase the number of transplants
  • Provide equity in access to transplants
  • Promote living donor and transplant recipient safety
  • Improve waitlisted patient, living donor, and transplant recipient outcomes

COVID-19 operational actions reviewed, will remain in effect

The board reviewed several operational actions adopted by the OPTN Executive Committee in March and April, 2020, to help members document COVID 19-issues affecting organ donation and transplantation and to help members focus needed resources on essential clinical services. The board agreed to make permanent a requirement for OPTN members to document COVID-19 testing for all potential deceased donors. The board resolved that the following measures will remain in effect, subject to ongoing Executive Committee review for their applicability and effectiveness:

  • Updates to transplant candidate data if a transplant hospital is unable to bring a candidate in for updated lab testing due to COVID-19 issues
  • Relaxation of certain data submission requirements for follow-up of transplant recipients and living donors
  • Modifications to reporting wait time initiation for kidney transplant candidates who are not on dialysis

Other actions

The board took additional actions as follows:

  • Approved new and amended OPTN policies to align with recently updated recommendations from the U.S. Public Health Service to assess organ donors and monitor transplant recipients for potential HIV, hepatitis B and hepatitis C infection
  • Endorsed a slate of nominees for election to open positions on the board for terms beginning July 1, 2021
  • Approved the programming into the UNetSM system of allocation policy for vascularized composite allografts (VCA)
  • Modified data collection requirements for living VCA donors
  • Accepted new guidance and updated policy regarding adult heart allocation, to standardize and streamline data reporting for candidates with certain clinical conditions
  • Adopted guidance addressing the use of exception requests for pediatric heart candidates
  • Approved additional updates to operational processes and guidance for the National Liver Review Board, to clarify guidance and better ensure expert review of exception requests
  • Updated the cohort of data used to calculate the lung allocation score
  • Amended the OPTN Bylaws to permit all members of the board to vote on the full slate of representatives to the OPTN Executive Committee

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Implementation notice: Waitlist℠ programming updates to local acceptance criteria for heart, lung, heart-lung, liver and intestine

Implementation date:

  • Dec. 3: Heart, lung, heart-lung, liver and intestine


For heart, lung, heart-lung, liver and intestine programs, local donor acceptance criteria in Waitlist℠ have been updated in order to provide additional efficiency in organ allocation. Transplant programs should evaluate their current settings.

Summary of changes

With the transition away from donation service area (DSA) as a unit of allocation, a new framework has been developed to determine what type of offers would be screened using “local” acceptance criteria for a candidate. Because proximity to the donor hospital is a primary factor in the revised allocations, changes have been made to allow the location of the donor hospital in relation to the candidate to be considered when “local” acceptance criteria are applied.  Read additional background information here.

For each organ type, the following new local acceptance criteria will be used to include candidates on the match run:

  • Offers to candidates listed at transplant programs within the DSA and/or within 250 NM of the donor hospital:
    • Heart
    • Heart-lung
    • Lung
  • Offers to candidates listed at transplant programs within the DSA and/or within 150 NM of the donor hospital:
    • Liver
  • Offers to candidates listed at transplant programs within the DSA and/or within 500 NM of the donor hospital:
    • Intestine

Similar changes will be implemented for kidney and pancreas allocation on Dec. 15, when DSA and region are removed from distribution of those organs.

The inclusion of DSA in this definition does not impact the order of the match run as that is established and organized by distance-based allocation definitions within OPTN policy.

What you need to do

Transplant programs for all organ types should evaluate their current “local” acceptance criteria settings for candidates in Waitlist and determine if updates are appropriate based on the revised definition of “local” donor acceptance criteria.

Additional resources

Find professional education on UNOS Connect:

  • QLT103D Acceptance Criteria for Distance-based Allocation

In addition, DonorNet® online help documentation has been updated so that transplant programs will have access to the information about how local acceptance criteria is used for offers for all organ types.


If you have questions relating to implementation, contact UNOS Customer Service at, or call 1-800-978-4334 from 8 a.m. to 7 p.m. EST.

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Medicare and Medicaid Programs; Organ Procurement Organizations Conditions for Coverage: Revisions to the Outcome Measure Requirements for Organ Procurement Organizations

This final rule revises the Organ Procurement Organizations (OPOs) Conditions for Coverage (CfCs) to increase donation rates and organ transplantation rates by replacing the current outcome measures with new transparent, reliable, and objective outcome measures and increasing competition for open donation service areas (DSAs).