To facilitate the implementation of controlled donation after circulatory death (cDCD) programs even in hospitals not equipped with a local Extracorporeal Membrane Oxygenation (ECMO) team (Spokes), some countries and Italian Regions have launched a local cDCD network with a ECMO mobile team who move from Hub hospitals to Spokes for normothermic regional perfusion (NRP) implantation in the setting of a cDCD pathway. While ECMO teams have been clearly defined by the Extracorporeal Life Support Organization, regarding composition, responsibilities and training programs, no clear, widely accepted indications are to date available for NRP teams. Although existing NRP mobile networks were developed due to the urgent need to increase the number of cDCDs, there is now the necessity for transplantation medicine to identify the peculiarities and responsibility of a NRP team for all those centers launching a cDCD pathway. Thus, in the present manuscript we summarized the characteristics of an ECMO mobile team, highlighting similarities and differences with the NRP mobile team. We also assessed existing evidence on NRP teams with the goal of identifying the characteristic and essential features of an NRP mobile team for a cDCD program, especially for those centers who are starting the program. Differences were identified between the mobile ECMO team and NRP mobile team. The common essential feature for both mobile teams is high skills and experience to reduce complications and, in the case of cDCD, to reduce the total warm ischemic time. Dedicated training programs should be developed for the launch of de novo NRP teams.

The shortage of organs for transplantation has led health professionals to look for alternative sources of donors. One of the avenues concerns donors who have died after circulatory arrest. This is a special situation because the organs from these donors are exposed to warm ischaemia-reperfusion lesions that are unavoidable during the journey of the organs from the donor to the moment of transplantation in the recipient. We will address and discuss the key issues from the perspective of team organization, legislation and its evolution, and the ethical framework. In a second part, the avenues to improve the quality of organs will be presented following the itinerary of the organs between the donor and the recipient. The important moments from the point of view of therapeutic strategy will be put into perspective. New connections between key players involved in pathophysiological mechanisms and implications for innate immunity and injury processes are among the avenues to explore. Technological developments to improve the quality of organs from these recipients will be analyzed, such as perfusion techniques with new modalities of temperatures and oxygenation. New molecules are being investigated for their potential role in protecting these organs and an analysis of potential prospects will be proposed. Finally, the important perspectives that seem to be favored will be discussed in order to reposition the use of deceased donors after circulatory arrest. The use of these organs has become a routine procedure and improving their quality and providing the means for their evaluation is absolutely inevitable.