Thoracoabdominal Normothermic Regional Perfusion Safely Preserves the Irreversibility of Death in a Pediatric Porcine DCD Model: Combined Cerebrovascular Doppler and Intracortical EEG Evidence

Background. Pediatric donation after controlled circulatory determination of death (pDCDD) remains essential to expand access to heart transplantation in children. Ethical concerns persist regarding the risk of inadvertent restoration of cerebral perfusion during thoracoabdominal normothermic regional perfusion (TA-NRP). While prior adult studies suggest effective cerebral isolation, pediatric-specific preclinical evidence is lacking. This study aimed to assess cerebral blood flow and bioelectrical activity during TA-NRP following supra-aortic vessel ligation and venting using a pDCDD porcine model. Methods. Six white piglets (8–11 kg) underwent withdrawal of life-sustaining therapy and controlled circulatory arrest. After death declaration, TA-NRP was initiated following cannulation of the abdominal aorta and inferior vena cava and ligation, transection, and venting of the supra-aortic trunks. In 2 animals, angiographic contrast injection was performed to confirm vascular isolation. Cerebrovascular Doppler (CvD) was performed in all animals, and intracortical electroencephalogram in 4. Results. All animals achieved successful cardiac recovery under TA-NRP. Contrast angiography demonstrated complete absence of craniocervical opacification. CvD recordings before withdrawal showed physiological flow, whereas CvD during TA-NRP confirmed the absence of measurable flow bilaterally in all cases. Intracortical electroencephalogram showed progressive suppression of activity after circulatory arrest, culminating in persistent isoelectric tracing throughout TA-NRP. Conclusions. In this pediatric preclinical model, supra-aortic clamping and venting reliably prevented restoration of cerebral perfusion and bioelectrical activity during TA-NRP. These findings support the physiological and ethical validity of TA-NRP in pDCDD protocols and highlight its potential to expand pediatric heart transplantation while upholding the dead donor rule.