Vanderbilt adapts REUP technique to expand pediatric heart transplant access

Vanderbilt Health's cardiac surgeons have taken a technique that transformed adult heart transplantation and successfully reshaped it for children—a shift that could meaningfully alter the calculus of waiting for a pediatric heart.

The method is called REUP, shorthand for rapid recovery with extended ultraoxygenated preservation. It works by flushing a donor heart with cold, oxygen-rich solution after circulatory death, then preserving it without the need to restart the organ before transplant. The adult heart transplant team at Vanderbilt developed it to expand the pool of usable donor hearts. Now, surgeons at Monroe Carell Jr. Children's Hospital at Vanderbilt have adapted it for pediatric patients, and the early results suggest the technique carries real promise.

In a recent article published in the New England Journal of Medicine, the pediatric team reported on five children who received donor hearts using this adapted approach. The recipients ranged from a 2-day-old infant to a 14-year-old. They waited an average of 20 days for their transplants. All five received hearts that, under previous protocols, would have been discarded. None of the children required mechanical circulatory support after surgery. None showed signs of rejection during the study period. All demonstrated strong heart function.

The backdrop matters here. More than 2,000 children sit on the heart transplant waitlist each year in the United States. For neonates and infants especially, the wait can stretch for months. About one in five children on that list die before receiving a transplant. Those numbers have held relatively steady, constrained by the simple scarcity of donor hearts suitable for pediatric recipients. The previous methods for recovering hearts from donors after circulatory death required either reanimating the organ inside the donor's body or using specialized perfusion devices—approaches that raised ethical questions in some settings, demanded expensive equipment, and sometimes proved impractical for very small patients.

REUP sidesteps those complications. By preserving the heart without reanimation, the technique eliminates the ethical concerns that had made certain donor hearts unavailable in some regions. It also simplifies logistics and works across pediatric age groups. Aaron Williams, the first author of the NEJM article and an assistant professor of cardiac surgery at Vanderbilt, noted that the technique has already proven itself in adults, allowing surgeons to transplant more patients and recover hearts from greater distances. Adapting it for children opens similar possibilities: more donor hearts available, shorter waits, more young lives saved.

Ziv Beckerman, the surgical director of pediatric heart transplantation at Monroe Carell, called the innovation transformative. He emphasized that every heart recovered in the pediatric study came from a setting where donor reanimation was ethically prohibited—meaning without REUP, those hearts simply would not have been transplantable. Since the initial five cases reported in the journal, five more children have received transplants using the same technique, suggesting the early success was not an outlier.

The team is now working to help other pediatric heart transplant programs adopt the method. If that effort succeeds, the impact could ripple across the country: shorter waits for children already on the list, fewer deaths while waiting, and a meaningful expansion of the donor pool. The technique does not solve the fundamental shortage of donor hearts, but it does make better use of the hearts that become available—and in pediatric transplantation, where every month of waiting carries real risk, that distinction matters.