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Key points Despite growing interest in right ventricular form and function in diseased states, there is a paucity of data regarding characteristics of right ventricular function – namely contractile and lusitropic reserve, as well as ventricular‐arterial coupling, in the healthy heart during rest, as well as submaximal and peak exercise. Pressure‐volume analysis of the right ventricle, during invasive cardiopulmonary exercise testing, demonstrates that that the right heart has enormous contractile reserve, with a three‐ or fourfold increase in all metrics of contractility, as well as myocardial energy production and utilization. The healthy right ventricle also demonstrates marked augmentation in lusitropy, indicating that diastolic filling of the right heart is not passive. Rather, the right ventricle actively contributes to venous return during exercise, along with the muscle pump. Ventricular‐arterial coupling is preserved during submaximal and peak exercise in the healthy heart.AbstractKnowledge of right ventricular (RV) function has lagged behind that of the left ventricle and historically, the RV has even been referred to as a ‘passive conduit’ of lesser importance than its left‐sided counterpart. Pressure‐volume (PV) analysis is the gold standard metric of assessing ventricular performance. We recruited nine healthy sedentary individuals free of any cardiopulmonary disease (42 ± 12 years, 78 ± 11 kg), who completed invasive cardiopulmonary exercise testing during upright ergometry, while using conductance catheters inserted into the RV to generate real‐time PV loops. Data were obtained at rest, two submaximal levels of exercise below ventilatory threshold, to simulate real‐world scenarios/activities of daily living, and maximal effort. Breath‐by‐breath oxygen uptake was determined by indirect calorimetry. During submaximal and peak exercise, there were significant increases in all metrics of systolic function by three‐ to fourfold, including cardiac output, preload recruitable stroke work, and maximum rate of pressure change in the ventricle (dP/dtmax), as well as energy utilization as determined by stroke work and pressure‐volume area. Similarly, the RV demonstrated a significant, threefold increase in lusitropic reserve throughout exercise. Ventricular‐arterial coupling, defined by the quotient of end‐systolic elastance and effective arterial elastance, was preserved throughout all stages of exercise. Maximal pressures increased significantly during exercise, while end‐diastolic volumes were essentially unchanged. Overall, these findings demonstrate that the healthy RV is not merely a passive conduit, but actively participates in cardiopulmonary performance during exercise by accessing an enormous amount of contractile and lusitropic reserve, ensuring that VA coupling is preserved throughout all stages of exercise.

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Mortality on the liver waitlist remains unacceptably high. Donation after circulatory determination of death (DCD) donors are considered marginal but are a potentially underutilized resource. Thoraco‐abdominal normothermic perfusion (TA‐NRP) in DCD donors might result in higher quality livers and offset waitlist mortality. We retrospectively reviewed outcomes of the first 13 livers transplanted from TA‐NRP donors in the US. Nine centers transplanted livers from eight organ procurement organizations. Median donor age was 25 years; median agonal phase was 13 minutes. Median recipient age was 60 years; median lab MELD score was 21. Three patients (23%) met early allograft dysfunction (EAD) criteria. Three received simultaneous liver‐kidney transplants; neither had EAD nor delayed renal allograft function. One recipient died 186 days post‐transplant from sepsis but had normal presepsis liver function. One patient developed a biliary anastomotic stricture, managed endoscopically; no recipient developed clinical evidence of ischemic cholangiopathy (IC). Twelve of 13 (92%) patients are alive with good liver function at 439 days median follow‐up; one patient has extrahepatic recurrent HCC. TA‐NRP DCD livers in these recipients all functioned well, particularly with respect to IC, and provide a valuable option to decrease deaths on the waiting list.