Expanding Pediatric Liver Transplant Options: On-pump Split Reduction With Normothermic Machine Perfusion

Background. – Reduction and split liver transplantation are established strategies to address organ shortages in pediatric recipients, but they are traditionally performed under static cold storage, which limits ischemia tolerance and precludes functional assessment. Normothermic machine perfusion (NMP) enables active graft preservation, monitoring, and intervention, yet its use for pediatric liver reduction or splitting has not been reported. Methods. – An 8-y-old pediatric donor liver was procured onto the TransMedics Organ Care System and transported under continuous NMP. While on pump, the liver was surgically reduced to a left lateral segment using a living-donor hepatectomy approach. After reduction, the graft was flushed, divided, and transplanted into a 2-mo-old infant with acute liver failure. Results. – The transplant was technically successful, with prompt recovery of graft function and no immediate perfusion-related complications observed. Conclusions. – This first-in-human experience demonstrates the feasibility of on-pump liver reduction during NMP in pediatric transplantation and suggests potential advantages in graft assessment, ischemia mitigation, and operative precision.