End-ischemic viability testing by normothermic machine perfusion (NMP) represents an effective strategy to recover liver grafts having initially been discarded for liver transplantation (LT). However, its results in the setting of significant (≥ 30%) macrovesicular steatosis (MaS) have not been specifically assessed. Prospectively maintained databases at two high-volume LT centres in Northern Italy were searched to identify cases of end-ischemic NMP performed to test viability of livers with MaS ≥ 30% in the period Jan 2019 - Jan 2022. 14 cases were retrieved, representing 57.9% of NMP and 5.7% of all machine perfusion procedures. Of those, 10 (71%) were transplanted. Two patients developed primary non-function (PNF) and required urgent re-LT, both characterized by incomplete or suboptimal lactate clearance during NMP. PNF cases were also characterized by higher perfusate transaminases, lower hepatic artery and portal vein flow at two hours, and lack of glucose metabolism in one case. The remaining 8 patients showed good liver function (L-GrAFT score = -1.9 [risk 13.6%]; EASE score = -3.7 [risk 2.6%]) and had a favorable postoperative course. Overall, NMP allowed successful transplantation of 57% of livers with moderate-to-severe MaS. Our findings suggest that prolonged observation (≥ 6 hours) might be required for steatotic livers, and that stable lactate clearance is a fundamental prerequisite for their utilization.