In Italy, 20 minutes of a continuous flat line on an electrocardiogram are required for declaration of death. In the setting of donation after circulatory death (DCD), prolonged warm ischemia time prompted the introduction of abdominal normothermic regional perfusion (NRP) followed by postprocurement ex situ machine perfusion (MP). This is a retrospective review of DCD liver transplantations (LTs) performed at 2 centers using sequential NRP and ex situ MP. From January 2018 to April 2019, 34 DCD donors were evaluated. Three (8.8%) were discarded before NRP, and 11 (32.4%) were discarded based on NRP parameters (n = 1, 3.0%), liver macroscopic appearance at procurement and/or biopsy results (n = 9, 26.5%), or severe macroangiopathy at back‐table evaluation (n = 1, 3.0%). A total of 20 grafts (58.8%; 11 uncontrolled DCDs, 9 controlled DCDs) were considered eligible for LT, procured and perfused ex situ (9 normothermic and 11 dual hypothermic MPs). In total, 18 (52.9%; 11 uncontrolled) livers were eventually transplanted. Median (interquartile range) no‐flow time was 32.5 (30‐39) minutes, whereas median functional warm ischemia time was 52.5 (47‐74) minutes (controlled DCD), and median low‐flow time was 112 minutes (105‐129 minutes; uncontrolled DCD). There was no primary nonfunction, while postreperfusion syndrome occurred in 8 (44%) recipients. Early allograft dysfunction happened in 5 (28%) patients, while acute kidney injury occurred in 5 (28%). After a median follow‐up of 15.1 (9.5‐22.3) months, 1 case of ischemic‐type biliary lesions and 1 patient death were reported. DCD LT is feasible even with the 20‐minute no‐touch rule. Strict NRP and ex situ MP selection criteria are needed to optimize postoperative results.

creased risk of primary non-function (PNF), initial poor function (IPF), and long-term worse outcome are associated with ECD liver grafts (López-Navidad and Caballero, 2003;Feng et al., 2006;Dondossola et al., 2017a). Among ECDs, donors after cardiocirculatory death (DCD), in particular type II DCD -unexpected cardiac arrest with unsuccessful resuscitation (Thuong et al., 2016) -represent a major organ source with a significant potential to increase the number of donations (Blackstock and Ray, 2014;Manyalich et al., 2018). However, DCD can have detrimental effects on post-transplant survival and quality of life. For this reason, there is a high discard rate of these grafts. The DCD-related problems mainly stem from prolonged warm ischemia time (WIT), which reduces the tissue energy pool leading to cell death (Merlen et al.,

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