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Hang D, Chandrashekarappa K, Schilling K, Ubert A, de Oliveira N, Pagel PS. A two-circuit strategy for intraoperative extracorporeal support during single lung transplantation in a patient bridged with venovenous extracorporeal membrane oxygenation. Perfusion 2024; 39:281-284. [PMID: 36301682 DOI: 10.1177/02676591221137471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
Venovenous extracorporeal membrane oxygenation is increasingly used as a bridging strategy in decompensating patients awaiting lung transplantation. Various approaches for continuing support intraoperatively have been previously described. A two-circuit strategy that uses the in situ venovenous extracorporeal membrane oxygenation circuit supplemented with peripheral cardiopulmonary bypass allows for diversion of native cardiac output away from the transplanted lung as well as seamless continuation of venovenous extracorporeal membrane oxygenation postoperatively.
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Affiliation(s)
- Dustin Hang
- Medical College of Wisconsin Department of Anesthesiology, Milwaukee, WI, USA
| | | | - Kyle Schilling
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Adam Ubert
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Nilto de Oliveira
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paul S Pagel
- Anesthesiology, Clement J Zablocki VA Medical Center, Milwaukee, WI, USA
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2
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Laskey D, Housman B, Dawodu G, Scheinin S. Intraoperative Extracorporeal Support during Lung Transplantation: Not Just for the High-Risk Patient. J Clin Med 2023; 13:192. [PMID: 38202198 PMCID: PMC10779858 DOI: 10.3390/jcm13010192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
The use of intraoperative mechanical support during lung transplantation has traditionally been a controversial topic. Trends for intraoperative mechanical support strategies swing like a pendulum. Historically, cardiopulmonary bypass (CPB) was the modality of choice during transplantation. It provides full hemodynamic support including oxygenation and decarboxylation. Surgical exposure is improved by permitting the drainage of the heart and provides more permissive retraction. CPBs contain drainage reservoirs with hand-held pump suction catheters promoting blood conservation through collection and re-circulation. But CPB has its disadvantages. It is known to cause systemic inflammation and coagulopathy. CPB requires high doses of heparinization, which increases bleeding risks. As transplantation progressed, off-pump transplantation began to trend as a preferable option. ECMO, however, has many of the benefits of CPB with less of the risk. Outcomes were improved with ECMO compared to CPB. CPB has a higher blood transfusion requirement, a higher need for post-operative ECMO support, a higher re-intubation rate, high rates of kidney injury and need for hemodialysis, longer ICU stays, higher incidences of PGD grade 3, as well as overall in-hospital mortality when compared with ECMO use. The focus now shifts to using intraoperative mechanical support to protect the graft, helping to reduce ischemia-reperfusion injury and allowing for lung protective ventilator settings. Studies show that the routine use of ECMO during transplantation decreases the rate of primary graft dysfunction and many adverse outcomes including ventilator time, need for tracheostomy, renal failure, post-operative ECMO requirements, and others. As intraoperative planned ECMO is considered a safe and effective approach, with improved survival and better overall outcomes compared to both unplanned ECMO implementation and off-pump transplantation, its routine use should be taken into consideration as standard protocol.
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Affiliation(s)
- Daniel Laskey
- Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, One Gustave L. Levy Place, Box 1023, New York, NY 10029, USA; (B.H.); (G.D.); (S.S.)
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Hartwig M, van Berkel V, Bharat A, Cypel M, Date H, Erasmus M, Hoetzenecker K, Klepetko W, Kon Z, Kukreja J, Machuca T, McCurry K, Mercier O, Opitz I, Puri V, Van Raemdonck D. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation. J Thorac Cardiovasc Surg 2023; 165:301-326. [PMID: 36517135 DOI: 10.1016/j.jtcvs.2022.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/26/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation. METHODS The AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement. RESULTS The expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively. CONCLUSIONS Achieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for transplantation.
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Affiliation(s)
- Matthew Hartwig
- Division of Thoracic Surgery, Duke University Medical Center, Durham, NC.
| | | | | | | | - Hiroshi Date
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Michiel Erasmus
- University Academic Center Groningen, Groningen, The Netherlands
| | | | | | | | - Jasleen Kukreja
- University of California San Francisco, San Francisco, Calif
| | - Tiago Machuca
- University of Florida College of Medicine, Gainesville, Fla
| | | | - Olaf Mercier
- Université Paris-Saclay and Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | | | - Varun Puri
- Washington University School of Medicine, St Louis, Mo
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Calabrese F, Pezzuto F, Fortarezza F, Lunardi F, Faccioli E, Lorenzoni G, Boscolo A, Sella N, Gregori D, Schiavon M, Navalesi P, Dell’Amore A, Rea F. Evaluation of Tissue Ischemia/Reperfusion Injury in Lung Recipients Supported by Intraoperative Extracorporeal Membrane Oxygenation: A Single-Center Pilot Study. Cells 2022; 11:cells11223681. [PMID: 36429108 PMCID: PMC9688824 DOI: 10.3390/cells11223681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/10/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
Intraoperative veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) as intraoperative hemodynamic support during lung transplantation is becoming a standard practice due to promising clinical results. Nevertheless, studies on tissue/molecular pathways investigating ischemia/reperfusion injury are still lacking. Patients receiving a bilateral lung transplantation between January 2012 and December 2018 at the University Hospital of Padova were included in this retrospective single-center observational study. The present study aimed to investigate ischemia/reperfusion injury in 51 tissue specimens obtained from 13 recipients supported by intraoperative VA-ECMO and 38 who were not. Several tissue analyses, including apoptosis evaluation and inducible nitric oxide synthase expression, were performed on the biopsies at the time of transplantation. Lung samples from the ECMO group (both pre- and post-reperfusion) were comparable, or for some parameters better, than samples from the non-ECMO group. Leukocyte margination was significantly lower in the ECMO group than in the non-ECMO group. Primary graft dysfunction, mainly at 24 and 48 h, was correlated with the tissue injury score of the post-reperfusion biopsy. The interquartile ranges for all morphological parameters showed high grade variability between pre- and post-reperfusion in the non-ECMO group. These preliminary data support the use of intraoperative ECMO based on lower lung tissue ischemia/reperfusion injury. Larger case series are mandatory to confirm our findings.
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Affiliation(s)
- Fiorella Calabrese
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-0498272268
| | - Federica Pezzuto
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
| | - Francesco Fortarezza
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
| | - Francesca Lunardi
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
| | - Eleonora Faccioli
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
| | - Giulia Lorenzoni
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
| | - Annalisa Boscolo
- Institute of Anesthesia and Intensive Care, Padova University Hospital, 35128 Padova, Italy
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Nicolò Sella
- Institute of Anesthesia and Intensive Care, Padova University Hospital, 35128 Padova, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
| | - Marco Schiavon
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
| | - Paolo Navalesi
- Institute of Anesthesia and Intensive Care, Padova University Hospital, 35128 Padova, Italy
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Andrea Dell’Amore
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
| | - Federico Rea
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
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Park S, Kim YT. Technical Aspects of Lung Transplantation: General Considerations. J Chest Surg 2022; 55:301-306. [PMID: 35924537 PMCID: PMC9358160 DOI: 10.5090/jcs.22.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 11/16/2022] Open
Abstract
Surgical approaches to lung transplantation in adults vary substantially among surgeons and institutions, but the underlying principles are consistent. This article provides a surgical overview of bilateral sequential lung transplantation.
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Affiliation(s)
- Samina Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Niikawa H, Okamoto T, Ayyat KS, Itoda Y, Sakanoue I, Farver CF, Yun JJ, McCurry KR. Prone Ex Vivo Lung Perfusion Protects Human Lungs from Reperfusion Injury. Artif Organs 2022; 46:2226-2233. [DOI: 10.1111/aor.14328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/08/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Hiromichi Niikawa
- Department of Inflammation and Immunity Lerner Research Institute; Cleveland Clinic Cleveland OH U.S.A
- Department of Thoracic and Cardiovascular Surgery; Cleveland Clinic Cleveland OH U.S.A
| | - Toshihiro Okamoto
- Department of Inflammation and Immunity Lerner Research Institute; Cleveland Clinic Cleveland OH U.S.A
- Department of Thoracic and Cardiovascular Surgery; Cleveland Clinic Cleveland OH U.S.A
| | - Kamal S. Ayyat
- Department of Inflammation and Immunity Lerner Research Institute; Cleveland Clinic Cleveland OH U.S.A
- Department of Thoracic and Cardiovascular Surgery; Cleveland Clinic Cleveland OH U.S.A
- Department of Cardiothoracic Surgery Zagazig University Zagazig Egypt
| | - Yoshifumi Itoda
- Department of Inflammation and Immunity Lerner Research Institute; Cleveland Clinic Cleveland OH U.S.A
- Department of Thoracic and Cardiovascular Surgery; Cleveland Clinic Cleveland OH U.S.A
| | - Ichiro Sakanoue
- Department of Inflammation and Immunity Lerner Research Institute; Cleveland Clinic Cleveland OH U.S.A
- Department of Thoracic and Cardiovascular Surgery; Cleveland Clinic Cleveland OH U.S.A
| | - Carol F. Farver
- Department of Anatomic Pathology; Cleveland Clinic Cleveland OH U.S.A
| | - James J. Yun
- Department of Inflammation and Immunity Lerner Research Institute; Cleveland Clinic Cleveland OH U.S.A
- Department of Thoracic and Cardiovascular Surgery; Cleveland Clinic Cleveland OH U.S.A
- Transplant Center; Cleveland Clinic Cleveland OH U.S.A
| | - Kenneth R. McCurry
- Department of Inflammation and Immunity Lerner Research Institute; Cleveland Clinic Cleveland OH U.S.A
- Department of Thoracic and Cardiovascular Surgery; Cleveland Clinic Cleveland OH U.S.A
- Transplant Center; Cleveland Clinic Cleveland OH U.S.A
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7
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Schwarz S, Hoetzenecker K, Klepetko W. Procedural mechanical support for lung transplantation. Curr Opin Organ Transplant 2021; 26:309-313. [PMID: 33782246 DOI: 10.1097/mot.0000000000000873] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The use of procedural mechanical support during lung transplantation (LTx) varies between centers and the optimal support strategy is still controversially discussed. The two main questions are if cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) should be preferred and whether mechanical support should be reserved for specific patient groups or a routine use can be recommended. RECENT FINDINGS Recent cohort studies have consistently shown that LTx on CPB leads to inferior outcomes when compared to venoarterial (va)-ECMO. Thus, ECMO should be preferred in lung transplantation except for special indications. Despite its higher invasiveness, ECMO offers some pivotal advantages over off-pump lung transplantation. It has been shown to remarkably reduce rates of primary graft dysfunction, supporting the concept of a routine intraoperative ECMO use in LTx. SUMMARY Although randomized-controlled trials addressing this question are still lacking, current evidence appears to favor the routine use of ECMO support during lung transplantation.
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Affiliation(s)
- Stefan Schwarz
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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8
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Tian D, Shiiya H, Sato M, Nakajima J. Rat lung transplantation model: modifications of the cuff technique. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:407. [PMID: 32355851 PMCID: PMC7186686 DOI: 10.21037/atm.2020.02.46] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Although the cuff technique in rat lung transplantation (LTx) has a long history, it remains technically challenging. We have developed key tricks and modifications in the devices and the cuff technique that optimize the rat LTx model to achieve successful operations during a short learning period. Methods Altogether, 180 consecutive rats underwent orthotopic left LTx performed by a single surgeon using our modified devices and procedures. Allogeneic and syngeneic transplantation were performed using Lewis rats as recipients and Brown Norway and Lewis rats as donors. Allogeneic recipients were treated with cyclosporine during the first week. Recipients were sacrificed at various time points after ≥2 weeks. Results A special cuff-preparation plate was created using a petri dish and two foam blocks. This modified plate stabilizes the preparation and prevents donor lung compression. A "┴"-shaped incision was carved into the front wall of the pulmonary artery (PA) using micro-scissors. "V"-shaped incisions were made from the inferior-to-superior branches of the pulmonary vein (PV) and bronchus. A "pendulum model" was applied at implantation to make the hilar anastomosis tension-free and technically easier to perform. There were no intraoperative complications. Ten rats (5.6%) experienced partial or full pulmonary atelectasis. Five deaths (2.8%) due to pleural effusion occurred during the follow-up period. The operative times for heart-lung block retrieval, cuff preparation, cold ischemia, warm ischemia, and total procedure time were 8.4±0.8, 11.6±1.5, 25.1±2.2, 8.1±1.2, and 46.7±2.8 min, respectively. Conclusions The key tricks and improvements we made in the cuff technique for rat LTx provided the advantages of expeditiousness, a low complication rate, and a high success rate.
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Affiliation(s)
- Dong Tian
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan.,Department of Thoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.,Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Haruhiko Shiiya
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan.,Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Jun Nakajima
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
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Abstract
Injuries sustained by donor heart and lung allografts during the transplantation process are multiple and cumulative. Optimization of allograft function plays an essential role in short- and long-term outcomes after transplantation. Therapeutic targets to prevent or attenuate injury are present in the donor, the preservation process, during transplantation, and in postoperative management of the recipient. The newest and most promising methods of optimizing donor heart and lung allografts are found in alternative preservation strategies, which enable functional assessment of donor organs and provide a modality to initiate therapies for injured allografts or prevent injury during reperfusion in recipients.
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Affiliation(s)
- Sue A Braithwaite
- Department of Anesthesiology, University Medical Center Utrecht, Mail Stop Q04.2.317, Postbus 85500, Utrecht 3508 GA, The Netherlands.
| | - Niels P van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Room E03.511, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
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Hoetzenecker K, Benazzo A, Stork T, Sinn K, Schwarz S, Schweiger T, Klepetko W. Bilateral lung transplantation on intraoperative extracorporeal membrane oxygenator: An observational study. J Thorac Cardiovasc Surg 2019; 160:320-327.e1. [PMID: 31932054 DOI: 10.1016/j.jtcvs.2019.10.155] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/05/2019] [Accepted: 10/07/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Intraoperative extracorporeal membrane oxygenation (ECMO) is usually reserved to support patients during complex lung transplantation. We hypothesized that a routine application of intraoperative ECMO in all patients improves primary graft function. METHODS Patients receiving a bilateral lung transplantation between November 2016 and July 2018 at the Medical University of Vienna were included in this prospective, single-center observational study. All transplantations were uniformly performed on central venoarterial ECMO support, with the possibility to extend ECMO into the early postoperative period whenever graft function did not meet established quality criteria at the end of implantation. Primary graft dysfunction (PGD) grades were evaluated at 24, 48, and 72 hours after transplantation. Perioperative complications and survival outcome were assessed. RESULTS A total of 159 patients were included in the study. At 24 hours post-transplantation, 38.4% (n = 61) of patients were already extubated, 48.4% (n = 77) were classified as PGD0, 4.4% (n = 7) as PGD1, 3.1% (n = 5) as PGD2, 2.5% (n = 4) as PGD3, and 3.1% (n = 5) were "ungradable" due to prophylactic postoperative prolongation of ECMO. At 72 hours after transplantation, 76.7% (n = 122) of the patients were extubated, as opposed to only 1.3% (n = 2) of patients classified as PGD3. The median time of mechanical ventilation was 29 hours (interquartile range, 17-58). The 90-day-mortality was 3.1%, and 2-year survival was 86%. CONCLUSIONS Routine use of intraoperative ECMO resulted in excellent primary graft function and mid-term outcome in patients undergoing lung transplantation. To the best of our knowledge, the herein measured PGD rates are the lowest reported in the literature to date. Our results advocate a routine intraoperative use of ECMO in bilateral lung transplantation.
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Affiliation(s)
- Konrad Hoetzenecker
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Alberto Benazzo
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Theresa Stork
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Katharina Sinn
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schweiger
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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Intraoperative extracorporeal support during lung transplantation in patients bridged with venovenous extracorporeal membrane oxygenation. J Heart Lung Transplant 2018; 37:1418-1424. [DOI: 10.1016/j.healun.2018.07.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 06/13/2018] [Accepted: 07/05/2018] [Indexed: 11/21/2022] Open
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12
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Report of the ISHLT Working Group on primary lung graft dysfunction Part IV: Prevention and treatment: A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2017; 36:1121-1136. [DOI: 10.1016/j.healun.2017.07.013] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 07/16/2017] [Indexed: 12/14/2022] Open
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13
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Lim HK, Jayaweera S, Calderone A, Pepe S, Rosenfeldt FL, Marasco SF. Protective role of Coenzyme Q10in two models of rat lung injury. ANZ J Surg 2010; 80:265-70. [DOI: 10.1111/j.1445-2197.2009.05085.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Prolonged venoarterial extracorporeal membrane oxygenation after transplantation restores functional integrity of severely injured lung allografts and prevents the development of pulmonary graft failure in a pig model. J Thorac Cardiovasc Surg 2009; 137:1493-8. [DOI: 10.1016/j.jtcvs.2008.11.064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Revised: 10/22/2008] [Accepted: 11/15/2008] [Indexed: 11/18/2022]
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16
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Okamoto T, Nakamura T, Zhang J, Aoyama A, Chen F, Fujinaga T, Shoji T, Hamakawa H, Sakai H, Manabe T, Wada H, Date H, Bando T. Successful sub-zero non-freezing preservation of rat lungs at -2 degrees C utilizing a new supercooling technology. J Heart Lung Transplant 2009; 27:1150-7. [PMID: 18926408 DOI: 10.1016/j.healun.2008.07.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Revised: 06/22/2008] [Accepted: 07/01/2008] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND A lower temperature, namely below 0 degrees C, has been thought to be desirable for organ preservation because of the lower rate of metabolism; however, its benefits are still poorly understood. Supercooling is a non-freezing state of liquid below the freezing point, and the new development of a refrigerator for supercooling has now made it possible to preserve organs at sub-zero temperatures in a non-frozen state without cryoprotectants. METHODS Rat lungs were ventilated and perfused for 60 minutes in the 3 groups (n = 7 each): (1) the fresh group, in which the lungs were reperfused immediately after harvesting; (2) the 4 degrees C group, in which the lungs were stored after harvesting in ET-Kyoto solution at 4 degrees C for 17 hours before reperfusion; and (3) the supercooling group, in which lungs were preserved in ET-Kyoto solution at -2 degrees C for 17 hours. RESULTS Ischemia-reperfusion injury was significantly attenuated in the supercooling group, with a decrease in the pulmonary artery pressure (p < 0.02) and weight gain (p < 0.001), and an increase in the tidal volume (p = 0.001) and arterial oxygen tension (p < 0.001) compared with the 4 degrees C group. In the supercooling group, most of these indicators were equivalent to the fresh lung, with less damage to the endothelial cells of the pulmonary arteries and higher levels of adenosine triphosphate than in the 4 degrees C group. CONCLUSIONS Lungs stored using this new supercooling method of lung preservation showed better organ function than conventional storage at 4 degrees C.
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Affiliation(s)
- Toshihiro Okamoto
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Guth S, Prüfer D, Kramm T, Mayer E. Length of pressure-controlled reperfusion is critical for reducing ischaemia-reperfusion injury in an isolated rabbit lung model. J Cardiothorac Surg 2007; 2:54. [PMID: 18067666 PMCID: PMC2228300 DOI: 10.1186/1749-8090-2-54] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2007] [Accepted: 12/07/2007] [Indexed: 11/30/2022] Open
Abstract
Background Ischaemia-reperfusion injury is still a major problem after lung transplantation. Several reports describe the benefits of controlled graft reperfusion. In this study the role of length of the initial pressure-controlled reperfusion (PCR) was evaluated in a model of isolated, buffer-perfused rabbit lungs. Methods Heart-lung blocks of 25 New Zealand white rabbits were used. After measurement of baseline values (haemodynamics and gas exchange) the lungs were exposed to 120 minutes of hypoxic warm ischaemia followed by repeated measurements during reperfusion. Group A was immediately reperfused using a flow of 100 ml/min whereas groups B, C and D were initially reperfused with a maximum pressure of 5 mmHg for 5, 15 or 30 minutes, respectively. The control group had no period of ischaemia or PCR. Results Uncontrolled reperfusion (group A) caused a significant pulmonary injury with increased pulmonary artery pressures (PAP) and pulmonary vascular resistance and a decrease in oxygen partial pressure (PO2), tidal volume and in lung compliance. All groups with PCR had a significantly higher PO2 for 5 to 90 min after start of reperfusion. At 120 min there was also a significant difference between group B (264 ± 91 mmHg) compared to groups C and D (436 ± 87 mmHg; 562 ± 20 mmHg, p < 0.01). All PCR groups showed a significant decrease of PAP compared to group A. Conclusion Uncontrolled reperfusion results in a severe lung injury with rapid oedema formation. PCR preserves pulmonary haemodynamics and gas exchange after ischaemia and might allows for recovery of the impaired endothelial function. 30 minutes of PCR provide superior results compared to 5 or 15 minutes of PCR.
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Affiliation(s)
- Stefan Guth
- Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg - University, Langenbeckstr, 1, 55131 Mainz, Germany.
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Bopassa JC, Vandroux D, Ovize M, Ferrera R. Controlled reperfusion after hypothermic heart preservation inhibits mitochondrial permeability transition-pore opening and enhances functional recovery. Am J Physiol Heart Circ Physiol 2006; 291:H2265-71. [PMID: 16798830 DOI: 10.1152/ajpheart.00209.2006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We investigated whether low-pressure reperfusion may attenuate postischemic contractile dysfunction, limits necrosis and apoptosis after a prolonged hypothermic ischemia, and inhibits mitochondrial permeability transition-pore (MPTP) opening. Isolated rats hearts (n = 72) were exposed to 8 h of cold ischemia and assigned to the following groups: 1) reperfusion with low pressure (LP = 70 cmH(2)O) and 2) reperfusion with normal pressure (NP = 100 cmH(2)O). Cardiac function was assessed during reperfusion using the Langendorff model. Mitochondria were isolated, and the Ca(2+) resistance capacity (CRC) of the MPTP was determined. Malondialdehyde (MDA) production, caspase-3 activity, and cytochrome c were also assessed. We found that functional recovery was significantly improved in LP hearts with rate-pressure product averaging 30,380 +/- 1,757 vs. 18,000 +/- 1,599 mmHg/min in NP hearts (P < 0.01). Necrosis, measured by triphenyltetrazolium chloride staining and creatine kinase leakage, was significantly reduced in LP hearts (P < 0.01). The CRC was increased in LP heart mitochondria (P < 0.01). Caspase-3 activity, cytochrome c release, and MDA production were reduced in LP hearts (P < 0.001 and P < 0.01). This study demonstrated that low-pressure reperfusion after hypothermic heart ischemia improves postischemic contractile dysfunction and attenuates necrosis and apoptosis. This protection could be related to an inhibition of mitochondrial permeability transition.
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Affiliation(s)
- J C Bopassa
- EMI-U 0226, Laboratoire de Physiologie, Faculté de Médecine Lyon-Nord, 8, Ave. Rockefeller, 69373 LYON Cedex 08, France
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Wierup P, Haraldsson A, Nilsson F, Pierre L, Scherstén H, Silverborn M, Sjöberg T, Westfeldt U, Steen S. Ex Vivo Evaluation of Nonacceptable Donor Lungs. Ann Thorac Surg 2006; 81:460-6. [PMID: 16427831 DOI: 10.1016/j.athoracsur.2005.08.015] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2005] [Revised: 08/03/2005] [Accepted: 08/15/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND Only a minority of the potential candidates for lung donation are considered suitable, using current evaluation methods. A new method for ex vivo evaluation, with the potential for reconditioning of marginal and nonacceptable lungs, has been developed. This is a report of the ex vivo evaluation of six donor lungs deemed nonacceptable (arterial oxygen pressure less than 40 kPa) by the Scandiatransplant, Eurotransplant, and UK transplant organizations. METHODS The lungs are perfused ex vivo with Steen solution, a lung evaluation-preservation solution, mixed with red blood cells to a hematocrit of 15%. This extracellular solution is designed to have an optimal colloid osmotic pressure so that physiologic pressure and flow can be maintained without development of pulmonary edema. An oxygenator connected to the extracorporeal circuit maintains a normal mixed venous blood gas level in the perfusate. The lungs are ventilated and evaluated through analyses of pulmonary vascular resistance, oxygenation capacity, and arterial carbon dioxide pressure minus end-tidal carbon dioxide difference. RESULTS The arterial oxygen pressure (inspired oxygen fraction, 1.0) increased from 27 kPa (range, 17 to 34 kPa) in situ in the organ donor at the referring hospital to 57 kPa (range, 39 to 66 kPa) during the ex vivo evaluation. The pulmonary vascular resistance varied from 3.2 to 5.7 Wood units, and the arterial carbon dioxide pressure minus end-tidal carbon dioxide difference was in the range of 1 to 2.5 kPa. CONCLUSIONS The arterial oxygen pressure improves significantly in this model. This ex vivo evaluation model is a valuable addition to the armamentarium in finding acceptable lungs in a donor population with inferior arterial oxygen pressure values.
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Affiliation(s)
- Per Wierup
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Schnickel GT, Ross DJ, Beygui R, Shefizadeh A, Laks H, Saggar R, Lynch JP, Ardehali A. Modified reperfusion in clinical lung transplantation: the results of 100 consecutive cases. J Thorac Cardiovasc Surg 2005; 131:218-23. [PMID: 16399315 DOI: 10.1016/j.jtcvs.2005.08.045] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Revised: 08/15/2005] [Accepted: 08/30/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Severe primary graft dysfunction occurs in 10% to 20% of lung transplant recipients and is the leading cause of early death after lung transplantation. We hypothesized that altering the content of the initial reperfusate and maintaining a low reperfusion pressure after surgical implantation would lead to a low incidence of primary graft dysfunction. METHODS We analyzed the records of all patients who underwent lung transplantation at our institution from March 1, 2000, to August 30, 2004. The modified reperfusion technique involved the insertion of a catheter into the main or individual pulmonary artery after implantation. The recipient blood was depleted of leukocytes; supplemented with nitroglycerin; adjusted for pH and calcium level; enriched with aspartate, glutamate, and dextrose; and then administered into the pulmonary arteries of the newly transplanted lung(s) for the first 10 minutes of reperfusion. Severe primary graft dysfunction was defined as a PaO2/inspired oxygen fraction of less than 150 with diffuse infiltrate on the radiograph in absence of other causes. RESULTS During this interval, 100 patients underwent lung transplantation with the modified reperfusion technique. Forty-two patients underwent single-lung transplantation, of which 5 patients required cardiopulmonary bypass for the procedure. Fifty-eight patients underwent double-lung transplantation; all double-lung transplantation procedures were performed with patients on cardiopulmonary bypass. There were no technical complications associated with the modified reperfusion. The mean PaO2/inspired oxygen fraction at 6 hours in this cohort was 252 +/- 123 mm Hg. The median number of days on the ventilator was 2. More importantly, the incidence of severe primary graft dysfunction in this cohort was 2.0%. The early survival (30-day or in-hospital mortality) of this group of patients was 97%. CONCLUSIONS The technique of modified reperfusion in human lung transplantation is associated with a low incidence of severe primary graft dysfunction and favorable short-term outcomes.
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Affiliation(s)
- Gabriel T Schnickel
- Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Calif, USA.
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Barr ML, Kawut SM, Whelan TP, Girgis R, Böttcher H, Sonett J, Vigneswaran W, Follette DM, Corris PA. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction Part IV: Recipient-Related Risk Factors and Markers. J Heart Lung Transplant 2005; 24:1468-82. [PMID: 16210118 DOI: 10.1016/j.healun.2005.02.019] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2004] [Revised: 02/07/2005] [Accepted: 02/17/2005] [Indexed: 12/27/2022] Open
Affiliation(s)
- Mark L Barr
- University of Southern California, Los Angeles, California 90033, USA.
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Bopassa JC, Michel P, Gateau-Roesch O, Ovize M, Ferrera R. Low-pressure reperfusion alters mitochondrial permeability transition. Am J Physiol Heart Circ Physiol 2005; 288:H2750-5. [PMID: 15653760 DOI: 10.1152/ajpheart.01081.2004] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We hypothesized that low-pressure reperfusion may limit myocardial necrosis and attenuate postischemic contractile dysfunction by inhibiting mitochondrial permeability transition pore (mPTP) opening. Male Wistar rat hearts (n = 36) were perfused according to the Langendorff technique, exposed to 40 min of ischemia, and assigned to one of the following groups: 1) reperfusion with normal pressure (NP = 100 cmH(2)O) or 2) reperfusion with low pressure (LP = 70 cmH(2)O). Creatine kinase release and tetraphenyltetrazolium chloride staining were used to evaluate infarct size. Modifications of cardiac function were assessed by changes in coronary flow, heart rate (HR), left ventricular developed pressure (LVDP), the first derivate of the pressure curve (dP/dt), and the rate-pressure product (RPP = LVDP x HR). Mitochondria were isolated from the reperfused myocardium, and the Ca(2+)-induced mPTP opening was measured using a potentiometric approach. Lipid peroxidation was assessed by measuring malondialdehyde production. Infarct size was significantly reduced in the LP group, averaging 17 +/- 3 vs. 33 +/- 3% of the left ventricular weight in NP hearts. At the end of reperfusion, functional recovery was significantly improved in LP hearts, with RPP averaging 10,392 +/- 876 vs. 3,969 +/- 534 mmHg/min in NP hearts (P < 0.001). The Ca(2+) load required to induce mPTP opening averaged 232 +/- 10 and 128 +/- 16 microM in LP and NP hearts, respectively (P < 0.001). Myocardial malondialdehyde was significantly lower in LP than in NP hearts (P < 0.05). These results suggest that the protection afforded by low-pressure reperfusion involves an inhibition of the opening of the mPTP, possibly via reduction of reactive oxygen species production.
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Affiliation(s)
- J C Bopassa
- Inserm E0226, Laboratoire de Physiologie Lyon-Nord, 8, Ave. Rockefeller, 69373 Lyon Cedex 08, France
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Liberalization of donor criteria for lung transplantation. Curr Opin Organ Transplant 2004. [DOI: 10.1097/01.mot.0000135413.44963.f4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Waldow T, Alexiou K, Witt W, Wagner FM, Kappert U, Knaut M, Matschke K. Protection of lung tissue against ischemia/reperfusion injury by preconditioning with inhaled nitric oxide in an in situ pig model of normothermic pulmonary ischemia. Nitric Oxide 2004; 10:195-201. [PMID: 15275865 DOI: 10.1016/j.niox.2004.04.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2003] [Revised: 04/26/2004] [Indexed: 11/17/2022]
Abstract
Topical administration of nitric oxide (NO) by inhalation is currently used as therapy in various pulmonary diseases, but preconditioning with NO to ameliorate lung ischemia/reperfusion (I/R) injury has not been fully evaluated. In this study, we investigated the effects of NO inhalation on functional pulmonary parameters using an in situ porcine model of normothermic pulmonary ischemia. After left lateral thoracotomy, left lung ischemia was maintained for 90 min, followed by a 5h reperfusion period (group I, n = 7). In group II (n = 6), I/R was preceded by inhalation of NO (10 min, 15 ppm). Animals in group III (n = 7) underwent sham surgery without NO inhalation or ischemia. In order to evaluate the effects of NO preconditioning, lung functional and hemodynamic parameters were measured, and the zymosan-stimulated release of reactive oxygen species in arterial blood was determined. Animals in group I developed significant pulmonary I/R injury, including pulmonary hypertension, a decreased pO(2) level in pulmonary venous blood of the ischemic lung, and a significant increase of the stimulated release of reactive oxygen species. All these effects were prevented, or the onset (release of reactive oxygen species) was delayed, by NO inhalation. These results indicate that preconditioning by NO inhalation before lung ischemia is protective against I/R injury in the porcine lung.
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Affiliation(s)
- Thomas Waldow
- Herzzentrum Dresden GmbH, Universitätsklinikum Carl Gustav Carus, 01307 Dresden, Germany.
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Ardehali A, Laks H, Russell H, Levine M, Shpiner R, Lackey S, Ross D. Modified reperfusion and ischemia-reperfusion injury in human lung transplantation. J Thorac Cardiovasc Surg 2003; 126:1929-34. [PMID: 14688708 DOI: 10.1016/s0022-5223(03)00976-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Ischemia-reperfusion injury remains a major cause of mortality and morbidity in clinical lung transplantation. Interaction of activated leukocytes with injured graft endothelial cells participates in the development of ischemia-reperfusion injury. We sought to determine if modification of the reperfusate (with depletion of leukocytes and alteration of its composition) would decrease the incidence of ischemia-reperfusion injury in human lung transplantation when compared with whole blood reperfusion in a historical group of patients. METHODS Between June 1999 and July 2001, 23 adult patients undergoing lung transplantation consented to modified reperfusion. After implantation, a catheter was inserted into the main or individual pulmonary arteries, and modified reperfusate was administered at a pressure less than 20 mm Hg. The modified reperfusate was depleted of leukocytes, supplemented with nitroglycerin, adjusted for pH and calcium level, and enriched with aspartate, glutamate, and dextrose. After 10 minutes of modified reperfusion, the removal of pulmonary artery clamp or weaning of cardiopulmonary bypass was performed per usual protocol. Age- and diagnosis-matched historical patients served as the control group. Ischemia-reperfusion injury was defined as Pao(2)/Fio(2) < 150 with diffuse infiltrate on the radiograph in absence of other causes. RESULTS There was no difference in donor age or oxygenation indices, recipient age, the number of patients requiring cardiopulmonary bypass, ischemia time, and recipient oxygenation indices between the modified reperfusate group and the control group. However, none of the patients in the modified reperfusate group developed ischemia-reperfusion injury in contrast to 5 patients in the control group (P <.05). The early survival in the modified reperfusate group was 96% versus 81% in the control group (P = NS). CONCLUSION This study suggests that modification of the reperfusate content decreases the incidence of ischemia-reperfusion injury in human lung transplantation when compared with whole blood reperfusion in a historical group of patients. Modified reperfusate may allow acceptance of marginal lungs and expansion of the donor pool.
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Affiliation(s)
- Abbas Ardehali
- Division of Cardiothoracic Surgery, Department of Medicine, University of California at Los Angeles, USA.
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Kawashima M, Nakamura T, Schneider S, Vollmar B, Lausberg HF, Bauer M, Menger MD, Schäfers HJ. Iloprost ameliorates post-ischemic lung reperfusion injury and maintains an appropriate pulmonary ET-1 balance. J Heart Lung Transplant 2003; 22:794-801. [PMID: 12873548 DOI: 10.1016/s1053-2498(02)00646-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Ischemia-reperfusion (I/R) injury of the lung involves increased pulmonary vascular resistance. Prostaglandins are thought to have a beneficial effect in lung transplantation, but their mechanism in I/R injury is unknown. We investigated whether iloprost, a stable prostacyclin analogue, prevents I/R-associated pulmonary vascular dysfunction and whether it affects endothelin-1 (ET-1) balance. METHODS In an isolated blood-perfusion model, we subjected lungs of Lewis rats to 45 minutes of ischemia at 37 degrees C and randomly allocated the lungs to 3 groups (n = 6 each): iloprost (33.3 nmol/liter) added to the perfusate before ischemia and reperfusion (ILO+IR), iloprost (33.3 nmol/liter) given only before reperfusion (ILO+R), and controls without iloprost treatment (ILO-). RESULTS Reperfusion induced marked pulmonary edema in non-treated controls (ILO-), which was attenuated in ILO+R lungs and completely prevented in ILO+IR lungs. At 60 minutes reperfusion, arterial oxygen tension was significantly greater in both ILO+R and ILO+IR lungs compared with ILO- controls. Mean pulmonary artery pressure and pulmonary vascular resistance were slightly decreased in the ILO+R and significantly decreased in the ILO+IR group compared with the ILO- controls. Plasma levels of big ET-1, measured in both afferent and efferent blood, showed that I/R results in increased pulmonary venous levels of big ET-1. Interestingly, the increased venoarterial ET-1 gradient in ILO- lungs decreased significantly in the ILO+IR group. CONCLUSIONS We demonstrated in an isolated lung perfusion model that iloprost ameliorates post-ischemic lung reperfusion injury and maintains an appropriate pulmonary ET-1 balance.
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Affiliation(s)
- Masahiro Kawashima
- Department of Thoracic and Cardiovascular Surgery, University of Saarland, Homburg/Saar, Germany
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27
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Aguiló R, Serra E, Togores B, de la Peña A, Santos C, Agustí AGN. Long-term (72 hours) preservation of rat lungs. J Thorac Cardiovasc Surg 2003; 125:907-12. [PMID: 12698155 DOI: 10.1067/mtc.2003.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to investigate whether the addition of ethanol to a preservation solution (as an antifreeze agent) might allow a reduction of the storage temperature to 0 degrees C without causing freezing damage and improve lung function after prolonged (72 hours) ischemia. METHODS Lungs from Sprague-Dawley rats were ventilated and perfused ex vivo at 37 degrees C for 60 minutes in the following experimental groups: (1) the no ischemia and reperfusion (no I-R) group (n = 7), in which lungs were studied immediately after harvesting; (2) the LPD24 (n = 7) and (3) LPD72 (n = 8) groups, in which, after harvesting, lungs were flushed and immersed in low-potassium dextran solution and stored deflated at 10 degrees C for 24 and 72 hours, respectively, until reperfusion; and (4) the TEST72 group (n = 9), in which lungs were flushed and immersed in Krebs-Henseleit buffer with added ethanol (10 mL/L) after harvesting and stored deflated at 0 degrees C for 72 hours until reperfusion. RESULTS Compared with the no I-R group, the other 3 groups had worse lung function, higher lung water content, and evidence of cell injury at reperfusion (P <.01). However, lung function at reperfusion (assessed on the basis of either effluent Po(2), peak airway pressure, or mean arterial pulmonary pressure) was better (P <.01) in the TEST72 group than in the LPD24 or LPD72 groups. Paradoxically, lung cell structure was better preserved in the LPD24 group than in the TEST72 group (or the LPD72 group). CONCLUSIONS In this experimental model of rat lung ischemia-reperfusion injury, a low preservation temperature (0 degrees C) combined with the addition of ethanol to the preservation solution improves lung function at reperfusion after 72 hours of ischemia but fails to maintain lung cell structure.
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Affiliation(s)
- Rafael Aguiló
- Serveis de Cirurgia Toràcica, Hospital Universitari Son Dureta, Palma de Mallorca, Spain
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Affiliation(s)
- Marc de Perrot
- Toronto Lung Transplant Program, Toronto General Hospital, University of Toronto, Ontario, Canada
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de Boer WJ, Hepkema BG, Loef BG, van der Bij W, Verschuuren EAM, de Vries HJ, Lems SPM, Ebels T. Survival benefit of cardiopulmonary bypass support in bilateral lung transplantation for emphysema patients. Transplantation 2002; 73:1621-7. [PMID: 12042650 DOI: 10.1097/00007890-200205270-00017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND This study is designed to examine a possible association of cardiopulmonary bypass (CPB) support and outcome of lung transplantation in a well-balanced group of emphysema patients. METHODS We performed a retrospective analysis of 62 consecutive primary bilateral lung transplantations for emphysema. Risk factors for their possible association with patient survival were analyzed by multivariate logistic regression. RESULTS The use of CPB support was associated with improved survival (odds ratio=0.25; P=0.038). The actuarial survival at 1 year was 97% for patients treated with CPB and 77% for patients treated without CPB support. In 28 patients (45%), 2 human leukocyte antigen (HLA)-DR mismatches between donor and recipient occurred, whereas 34 patients had 0 or 1 HLA-DR mismatches. The use of CPB support in the group with two HLA-DR mismatches was associated with improved survival (odds ratio=0.06; P=0.020). This association was not present in the group with 0 or 1 HLA-DR mismatches. CONCLUSIONS These results demonstrate a significant survival benefit of CPB support during bilateral lung transplantation in emphysema patients. The difference in survival benefit of CPB support between the patients with 0 or 1 HLA-DR mismatches and the patients with 2 HLA-DR mismatches indicates that the immunosuppressive effect of CPB support might be responsible for this survival benefit. The underlying immunological mechanism might be important in the future treatment of organ transplantation.
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Affiliation(s)
- Willem J de Boer
- Department of Cardiothoracic Surgery, University Hospital Groningen, 9700 RB Groningen, The Netherlands. W.J.de.Boer@ thorax.azg.nl
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Allen BS. The role of leukodepletion in limiting ischemia/reperfusion damage in the heart, lung and lower extremity. Perfusion 2002; 17 Suppl:11-22. [PMID: 12009081 DOI: 10.1191/0267659102pf555oa] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This article describes the experimental infrastructure and subsequent clinical application of a comprehensive reperfusion strategy to limit the injury following ischemia, resulting in an improvement in post operative organ function. In particular, it examines the role of luekodepletion in minimizing damage and improving functional outcome in the heart, lung and lower extremity. During cardiothoracic procedures, various organs can be subjected to temporary ischemia, particularly the heart (cardioplegic arrest), lung (transplant), and lower extremity (femoral canulation, IABP). The background of ischemia/reperfusion injury is discussed as it applies to each of these 3 organs, as well as findings that ischemia followed by reperfusion results in a similar injury in each organ. Data are then presented to demonstrate that a comprehensive reperfusion strategy, utilizing a modified substrate-enriched blood reperfusate delivered at a low pressure can limit this injury, and that adding white blood cell filtration significantly improves the efficacy of this approach. These principles have now been used in a series of patients undergoing various surgical procedures with excellent results. Application of these concepts may significantly improve the outcome in patients undergoing procedures which subject these organs to temporary ischemia.
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Affiliation(s)
- Bradley S Allen
- The Division of Cardiovascular Surgery, The Heart Institute for Children, Hope Children's Hospital, Oak Lawn, Illinois 60453, USA.
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Kurusz M, Roach JD, Vertrees RA, Girouard MK, Lick SD. Leukocyte filtration in lung transplantation. Perfusion 2002; 17 Suppl:63-7. [PMID: 12009087 DOI: 10.1191/0267659102pf556oa] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Controlled reperfusion of the transplanted lung has been used in nine consecutive patients to decrease manifestations of lung reperfusion injury. An extracorporeal circuit containing a roller pump, heat exchanger and leukodepleting filter is primed with substrate-enhanced reperfusion solution mixed with approximately 2000 ml of the patient's blood. This solution is slowly recirculated to remove leukocytes prior to reperfusion. When the pulmonary anastomoses are completed, the pulmonary artery is cannulated through the untied anastomosis using a catheter containing a pressure lumen for measurement of infusion pressure. An atrial clamp is left in place on the patient's native atrial cuff to decrease the risk of systemic air embolism during the brief period of reperfusion from the extracorporeal reservoir. During reperfusion, the water bath to the heat exchanger is kept at 35 degrees C and the flow rate for reperfusion solution is between 150 and 200 m/min, keeping the pulmonary artery pressure <14 mmHg. Eight of nine patients were ventilated on 40% inspired oxygen within a few hours of operation and 7/9 were extubated on or before postoperative day 1. Six of nine patients are long-term survivors.
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Affiliation(s)
- Mark Kurusz
- Department of Surgery, The University of Texas Medical Branch, Galveston 77555-0528, USA.
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33
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Marczin N, Royston D, Yacoub M. Pro: lung transplantation should be routinely performed with cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2000; 14:739-45. [PMID: 11139121 DOI: 10.1053/jcan.2000.18592] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- N Marczin
- Department of Cardiothoracic Surgery and Anaesthetics, National Heart and Lung Institute, Imperial College of Science Technology and Medicine, Harefield Hospital, United Kingdom
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Abstract
Heart and lung transplantation have become standard therapy for many patients with end-stage heart and lung disease. Successful transplantation requires preservation of allografts until they can be implanted and reperfused. In the decades since the transplantation of thoracic organs became a clinical reality, many advances have been made in preoperative donor management, procurement, and preservation techniques. This article summarizes the state of the art in heart and lung preservation and review some of the areas of current research that may lead to improvements in preservation techniques in the future.
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Affiliation(s)
- J V Conte
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA
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Lick SD, Brown PS, Kurusz M, Vertrees RA, McQuitty CK, Johnston WE. Technique of controlled reperfusion of the transplanted lung in humans. Ann Thorac Surg 2000; 69:910-2. [PMID: 10750782 DOI: 10.1016/s0003-4975(99)01436-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Reperfusion injury remains a significant and sometimes fatal problem in clinical lung transplantation. Controlled reperfusion of the transplanted lung using white cell-filtered, nutrient-enriched blood has been shown recently to significantly ameliorate reperfusion damage in a porcine model. We modified this experimental technique and applied it to human lung transplantation. METHODS Approximately 1,500 mL of arterial blood was slowly collected in a cardiotomy reservoir during the lung implant, and mixed to make a 4:1 solution of blood:modified Buckberg perfusate. This solution was passed through a leukocyte filter and into the transplant pulmonary artery for 10 minutes, at a controlled rate (200 mL/min) and pressure (less than 20 mm Hg), immediately before removal of the vascular clamp. RESULTS Five patients underwent lung transplantation (1 bilateral, 4 single lung) using this technique. All patients were ventilated on a 40% fraction of inspired oxygen within a few hours and extubated on or before the first postoperative day. CONCLUSIONS Controlled reperfusion of the transplanted lung with white cell-filtered, nutrient-enriched blood has given excellent functional results in our small initial clinical series.
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Affiliation(s)
- S D Lick
- Division of Cardiothoracic Surgery, The University of Texas Medical Branch, Galveston 77555-0528, USA.
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Halldorsson AO, Kronon MT, Allen BS, Rahman S, Wang T. Lowering reperfusion pressure reduces the injury after pulmonary ischemia. Ann Thorac Surg 2000; 69:198-203; discussion 204. [PMID: 10654513 DOI: 10.1016/s0003-4975(99)01104-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Controlled reperfusion with a modified solution limits pulmonary injury following ischemia. Our initial studies infused this modified reperfusate at a pressure of 40 to 50 mm Hg to insure distribution. However, perhaps a lower pressure, which is closer to the normal physiologic pressure in the lung, would improve results by decreasing sheer stress. METHODS Fifteen adult pigs underwent 2 hours of lung ischemia by clamping the left bronchus and pulmonary artery. Five (group 1) then underwent uncontrolled reperfusion by removing the vascular clamps and allowing unmodified blood to reperfuse the lung at a pulmonary artery pressure of 20 to 30 mm Hg. The other 10 pigs underwent controlled reperfusion by mixing blood from the femoral artery with a crystalloid solution, and infusing this modified reperfusate into the ischemic lung through the pulmonary artery for 10 minutes before removing the arterial clamp. In 5 (group 2), the modified solution was infused at a pressure of 40 to 50 mm Hg, and in 5 (group 3) 20 to 30 mm Hg. Lung function was assessed 60 minutes after reperfusion and expressed as percentage of control. RESULTS Compared to uncontrolled reperfusion (group 1), controlled reperfusion at a pressure of 40 to 50 mm Hg (group 2) significantly improved postreperfusion pulmonary compliance (77% versus 86%; p<0.001 versus group 1), and arterial/alveolar ratio (a/A) ratio (27% versus 52%; p<0.001 versus group 1); as well as decreased pulmonary vascular resistance (PVR) (198% versus 154%; p<0.001 versus group 1), lung water (84.3% versus 83.5%; p<0.001 versus group 1), and myeloperoxidase (0.35 versus 0.23 optical density/min/mg protein). Reducing the pressure of the modified reperfusate to 20 to 30 mm Hg further improved postreperfusion compliance (92%+/-1%; p<0.001 versus groups 1 and 2) and a/A ratio (76%+/-1%; p<0.001 versus groups 1 and 2); and lowered PVR (133%+/-2%; p<0.001 versus groups 1 and 2), lung water (82.7%+/-0.1%; p<0.001 versus groups 1 and 2), and myeloperoxidase (0.16%+/-0.01%; p<0.001 versus groups 1 and 2). CONCLUSIONS After 2 hours of pulmonary ischemia, a severe lung injury occurs following uncontrolled reperfusion, controlled reperfusion with a modified solution reduces this reperfusion injury, and lowering the pressure of the modified reperfusate to more physiologic levels (20 to 30 mm Hg) further reduces the reperfusion injury improving pulmonary function.
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Affiliation(s)
- A O Halldorsson
- Division of Cardiothoracic Surgery, Heart Institute for Children, Hope Children's Hospital, Oak Lawn, Illinois, USA
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Pierre AF, DeCampos KN, Liu M, Edwards V, Cutz E, Slutsky AS, Keshavjee SH. Rapid reperfusion causes stress failure in ischemic rat lungs. J Thorac Cardiovasc Surg 1998; 116:932-42. [PMID: 9832683 DOI: 10.1016/s0022-5223(98)70043-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Rapid reperfusion may be injurious to the ischemic lung. Our aim was to confirm that slow reperfusion improves postischemic pulmonary function and to elucidate the ultrastructural changes associated with slow versus rapid reperfusion. METHODS. We used an ex vivo perfused rat lung transplant model to study the effect of slow versus rapid reperfusion on subsequent lung function and morphologic conditional. Functional assessment was performed in (1) fresh lung, slowly reperfused; (2) fresh lung, rapidly reperfused; (3) ischemic lung (4 hours at 22 degrees C), slowly reperfused; and (4) ischemic lung, rapidly reperfused. RESULTS In group 4, the shunt fraction (P=.001), airway pressure (P=.001), and wet/dry ratio (P=.01) were significantly higher than in groups 1 through 3. Light and electron microscopy of slowly reperfused ischemic lungs (n=4) appeared normal. Rapidly reperfused ischemic lungs (n=4) demonstrated massive alveolar edema hemorrhage, and epithelial "blebbing" by light microscopy. Electron microscopy identified the blebbing as separation of the epithelial layer from an intact basement membrane by edema fluid. The epithelial layer was disrupted in numerous locations. Complete disruption of all layers of the blood-gas barrier was occasionally present. CONCLUSION Rapid reperfusion of the ischemic lung is an important contributing factor to reperfusion lung injury resulting in mechanical stress failure of the alveolar/capillary barrier. Gradual reintroduction of blood flow to the ischemic lung improves oxygenation.
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Affiliation(s)
- A F Pierre
- Division of Thoracic Surgery, The Toronto Hospital; the Department of Pathology, Hospital for Sick Children, Toronto, Ontario, Canada
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Van Raemdonck DE, Jannis NC, De Leyn PR, Flameng WJ, Lerut TE. Warm ischemic tolerance in collapsed pulmonary grafts is limited to 1 hour. Ann Surg 1998; 228:788-96. [PMID: 9860478 PMCID: PMC1191597 DOI: 10.1097/00000658-199812000-00010] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the length of warm ischemic tolerance in pulmonary grafts from non-heart-beating donors. SUMMARY BACKGROUND DATA If lungs could be retrieved for transplant after circulatory arrest, the shortage of donors might be significantly alleviated. Great concern, however, exists about the length of tolerable warm ischemia before cold preservation of pulmonary grafts retrieved from such non-heart-beating donors. METHODS The authors compared the influence of an increasing postmortem interval on graft function in an isolated, room air-ventilated rabbit lung model during blood reperfusion up to 4 hours. Four groups of cadavers (four animals per group) were studied. In group 1, lungs were immediately reperfused. In the other groups, cadavers with lungs deflated were left at room temperature for 1 hour (group 2), 2 hours (group 3), or 4 hours (group 4). RESULTS Pulmonary vascular resistance was enhanced in all ischemic groups compared with the control group. An increase was noted with longer postmortem intervals in peak airway pressure and in weight gain. A concomitant decline was observed in the venoarterial oxygen pressure gradient caused by progressive edema formation, as reflected by the wet-to-dry weight ratio at the end of reperfusion. CONCLUSIONS Warm ischemia resulted in increased pulmonary vascular resistance. Graft function in lungs retrieved 1 hour after death was not significantly worse than in nonischemic lungs. Therefore, 60 minutes of warm ischemia with the lung collapsed may be tolerated before cold storage. Further studies are necessary to investigate whether lungs retrieved from non-heart-beating donors will become a realistic alternative for transplant.
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Affiliation(s)
- D E Van Raemdonck
- Center for Experimental Surgery and Anesthesiology, Katholieke Universiteit Leuven, University Hospital Gasthuisberg, Belgium.
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Featherstone RL, Kelly FJ, Shattock MJ, Hearse DJ, Chambers DJ. Hypothermic preservation of isolated rat lungs in modified bicarbonate buffer, EuroCollins solution or St Thomas' Hospital cardioplegic solution. Eur J Cardiothorac Surg 1998; 14:508-15. [PMID: 9860208 DOI: 10.1016/s1010-7940(98)00188-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Inadequate preservation solutions limit lung storage times and, consequently, transplant programs. To address this problem we established an isolated, ventilated and perfused rat lung preparation. Here we report the effects of hypothermic storage in EuroCollins solution, St Thomas' Hospital cardioplegic solution and a modified bicarbonate buffer solution. METHODS Lungs from male Wistar rats (230-330 g) were perfused via the pulmonary artery with modified bicarbonate buffer (37 degrees C, 15 ml/min, constant flow) and ventilated by positive pressure (tidal volume:1.6-1.8 ml, 80 breaths/min). Vascular resistance (pulmonary artery pressure:perfusate flow ratio) and airways compliance (tidal volume:tracheal pressure ratio) were measured. After a control perfusion period (20 min), lungs were flushed with, then immersed in, bicarbonate buffer (4 degrees C) for varying periods (0-24 h). After storage, lung function was assessed during 20 min reperfusion. Having established a suitable period for study, storage in EuroCollins, St Thomas' Hospital cardioplegic solution or bicarbonate buffer were compared. RESULTS Pulmonary compliance (ml/cmH2O) was significantly (P < 0.05) reduced in lungs stored for 6 h in modified bicarbonate buffer (0.026 +/- 0.008), EuroCollins solution (0.013 +/- 0.002) or St Thomas' Hospital solution (0.025 +/- 0.005) compared to unstored lungs (0.068 +/- 0.007). Vascular resistance, (1.32 +/- 0.13 cmH2O/ml per min) in unstored lungs, was similar in lungs stored in St Thomas' Hospital solution but increased significantly in lungs stored in modified bicarbonate buffer (3.22 +/- 0.78 cmH2O/ml per min) or EuroCollins solution (4.66 +/- 0.57 cmH2O/ml per min). CONCLUSIONS Hypothermic storage of rat lungs for 6 h in modified bicarbonate buffer or St Thomas' Hospital solution causes less increase in vascular resistance on reperfusion than EuroCollins solution.
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Affiliation(s)
- R L Featherstone
- Cardiovascular Research, The Rayne Institute, St Thomas' Hospital, London, UK.
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Halldorsson AO, Kronon M, Allen BS, Rahman S, Wang T, Layland M, Sidle D. Controlled reperfusion prevents pulmonary injury after 24 hours of lung preservation. Ann Thorac Surg 1998; 66:877-84; discussion 884-5. [PMID: 9768945 DOI: 10.1016/s0003-4975(98)00673-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Posttransplantation lung reperfusion injury continues to be a major problem. We have shown that controlling the initial period of reperfusion limits this injury after 2 hours of warm lung ischemia. The effectiveness of this modality, however, is unknown after longer periods of cold ischemia, which more closely mimics the clinical situation. METHODS After baseline measurements, 10 pigs had the left lung flushed with a modified Euro-Collins solution, explanted, stored at 4 degrees C for 24 hours, and transplanted into 10 other pigs. Five (group 1) underwent uncontrolled reperfusion created by removal of the vascular clamps after implantation of the new left lung, mimicking the clinical situation. The other five (group 2) underwent controlled reperfusion, which we performed by taking blood from the femoral artery, mixing it with a crystalloid solution (using a mixer heater) to make the blood hyperosmolar, alkalotic, and substrate-enriched, and pumping it through a leukocyte-depleting filter into the transplanted lung for 10 minutes at a pressure of 20 to 30 mm Hg before removing the pulmonary artery clamp. The right pulmonary artery and bronchus were then ligated, and left lung function was assessed each hour for 4 hours and compared with baseline. RESULTS Controlled reperfusion (group 2) minimized the reperfusion injury, preserving posttransplant pulmonary compliance (92% +/- 1% versus 68% +/- 1%; p < 0.001), reducing the rise in pulmonary vascular resistance (27% +/- 2% versus 166% +/- 3%; p < 0.001), improving oxygenation (PO2, 425 +/- 14 versus 82 +/- 11 mm Hg; p < 0.001), and lowering myeloperoxidase activity (0.22 +/- 0.02 versus 0.45 +/- 0.02 deltaOD/mg protein per minute; p < 0.001) and tissue edema (83.0% +/- 0.3% versus 84.9% +/- 0.3%; p < 0.001) compared with uncontrolled reperfusion, which resulted in an injury so severe that 3 of 5 pigs died before the 4-hour measurements. CONCLUSIONS After 24 hours of cold ischemia uncontrolled reperfusion results in a severe pulmonary reperfusion injury. This injury is almost completely avoided by controlling the composition (modified solution and white blood cell filter) and conditions (pressure) of the reperfusion. Because this experiment mimics the clinical situation, it suggests surgeons should begin to use this modality to limit reperfusion injury after lung transplantation.
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Affiliation(s)
- A O Halldorsson
- Division of Cardiothoracic Surgery, University of Illinois at Chicago, 60612, USA
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Clark SC, Sudarshan C, Khanna R, Roughan J, Flecknell PA, Dark JH. Controlled reperfusion and pentoxifylline modulate reperfusion injury after single lung transplantation. J Thorac Cardiovasc Surg 1998; 115:1335-41. [PMID: 9628676 DOI: 10.1016/s0022-5223(98)70217-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Rodent models have suggested that initial low-pressure reperfusion of transplanted lungs reduces injury after ischemia. We investigated this phenomenon and the use of pentoxifylline in a porcine model of left single lung transplantation. METHODS Donor lungs were preserved with Euro-Collins solution for a mean ischemic time of 18.4 hours. Neutrophil trapping in the graft, pulmonary artery pressure, and gas exchange were assessed over a 12-hour period. Partial occlusion of the contralateral pulmonary artery allowed manipulation of the pulmonary artery pressure in the transplanted lung. Group A (n = 5) was perfused at a mean pulmonary artery pressure of 20 mm Hg, group B was reperfused at a mean pulmonary artery pressure of 45 mm Hg for 10 minutes before reducing the pressure to the same as group A, and group C was reperfused at a mean pressure of 20 mm Hg for 10 minutes, then increased to a mean of 45 mm Hg for the remainder of the experiment. Group D was reperfused as in group A with the addition of intravenous pentoxifylline. RESULTS Leukocyte sequestration was observed in the first 10 minutes after reperfusion in groups A, B, and C, with maximal sequestration at 2 minutes. Significantly more sequestration was observed in the first 6 minutes in group B than in groups A and C, which were similar. Pentoxifylline significantly reduced leukocyte sequestration. Pulmonary venous oxygen tension in the allograft lung was worst in group B. Groups A and C were similar, but group D was superior to all other groups (p < 0.001). CONCLUSIONS Low-pressure reperfusion, even when limited to the first 10 minutes, modulates reperfusion injury possibly through a leukocyte-dependent mechanism. The addition of pentoxifylline in the recipient confers significant additional benefit.
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Affiliation(s)
- S C Clark
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
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Van Raemdonck DE, Jannis NC, De Leyn PR, Flameng WJ, Lerut TE. Alveolar expansion itself but not continuous oxygen supply enhances postmortem preservation of pulmonary grafts. Eur J Cardiothorac Surg 1998; 13:431-40; discussion 440-1. [PMID: 9641343 DOI: 10.1016/s1010-7940(98)00046-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE If lungs could be retrieved for transplant after circulatory arrest, the shortage of donors might be significantly alleviated. Great controversy still exists concerning the optimal mode of preservation of pulmonary grafts in these non-heart-beating donors. METHODS Graft function was measured in an isolated room air-ventilated rabbit lung model during reperfusion with homologous, diluted (Hb +/- 8.0 g/dl) and deoxygenated (PaO2 +/- 40 mmHg) blood up to 4 h. Five groups of cadavers (n = 4 in each group) were studied: In the control group, lungs were immediately reperfused. In the other groups, cadavers were left at room temperature for 4 h after death with lungs either deflated (group 1), inflated with room air (group 2), or ventilated with room air (group 3) or 100% nitrogen (group 4). RESULTS After 1 h of reperfusion, significant differences were noted between group 1 and groups 2, 3, and 4 in peak airway pressure (27 +/- 5 cm H2O vs. 15 +/- 1 cm H2O, 17 +/- 2 cm H2O, and 16 +/- 1 cm H2O, respectively; P < 0.05), in weight gain (137 +/- 24 vs. 31 +/- 7, 30 +/- 3, and 30 +/- 2%, respectively; P < 0.05), and in veno-arterial oxygen pressure gradient (9 +/- 5 vs. 95 +/- 13, 96 +/- 7 and 96 +/- 4 mmHg, respectively; P < 0.05). Also, wet-to-dry weight ratio at end of reperfusion was significantly different (10.2 +/- 1.0 vs. 6.0 +/- 0.3. 5.2 +/- 0.3 and 5.4 +/- 0.5, respectively; P < 0.05). No significant differences in any of these parameters were observed between groups 2, 3, and 4. CONCLUSIONS These data suggest that: (1) pulmonary edema will develop in atelectatic lungs if reperfusion is delayed for 4 h after death; (2) postmortem room air-inflation is as good as ventilation in prolonging warm ischemic tolerance; (3) ventilation with room air is no different from that with nitrogen; (4) therefore, prevention of alveolar collapse appears to be the critical factor in protecting the warm ischemic lung from reperfusion injury independent of continuous oxygen supply.
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Affiliation(s)
- D E Van Raemdonck
- Center for Experimental Surgery and Anesthesiology, Katholieke Universiteit Leuven, Belgium.
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Halldorsson A, Kronon M, Allen BS, Bolling KS, Wang T, Rahman S, Feinberg H. Controlled reperfusion after lung ischemia: implications for improved function after lung transplantation. J Thorac Cardiovasc Surg 1998; 115:415-24; discussion 424-5. [PMID: 9475537 DOI: 10.1016/s0022-5223(98)70286-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Despite improvements in organ preservation, reperfusion injury remains a major source of morbidity and mortality after lung transplantation. This pilot study was designed to investigate the effects of controlled reperfusion after lung ischemia. METHODS Twenty adult pigs underwent 2 hours of warm lung ischemia by crossclamping the left bronchus and pulmonary artery. In five (group 1), the clamp was simply removed at the end of ischemia (uncontrolled reperfusion). The 15 other pigs underwent modified reperfusion using blood from the femoral artery to perfuse the lung through the pulmonary artery (pressure 40 to 50 mm Hg) for 10 minutes before removing the pulmonary artery clamp. In five (group 2), the blood was mixed with crystalloid, resulting in a substrate-enriched, hypocalcemic, hyperosmolar, alkaline solution. In five (group 3), the blood was circulated through a leukocyte-depleting filter, and the last five (group 4) underwent reperfusion with both a modified solution and white blood cell filter. Lung function was assessed 60 minutes after reperfusion, and biopsy specimens were taken. RESULTS Controlled reperfusion with both a white blood cell filter and modified solution (group 4) completely eliminated the reperfusion injury that occurred with uncontrolled reperfusion (group 1), resulting in complete preservation of compliance (98% +/- 1% vs 77% +/- 1%; p < 0.001, and arterial/alveolar ratio (97% +/- 2% vs 27% +/- 2%; p < 0.001); no increase in pulmonary vascular resistance (106% +/- 1% vs 198% +/- 1%; p < 0.001); lowered tissue edema (82.1% +/- 0.4% vs 84.3% +/- 0.2%; p < 0.001), and myeloperoxidase activity (0.18 +/- 0.02 vs 0.35 +/- 0.02 deltaOD/min/mg protein; p < 0.001). In contrast, using either a white blood cell filter or modified solution separately improved but did not avoid the reperfusion injury, resulting in pulmonary function and tissue edema levels that were intermediate between group 1 (uncontrolled reperfusion) and group 4 (white blood cell filter and modified solution). CONCLUSION After 2 hours of warm pulmonary ischemia, (1) a severe lung injury occurs after uncontrolled reperfusion, (2) controlled reperfusion with either a modified reperfusion solution or white blood cell filter limits, but does not avoid, a lung reperfusion injury, (3) reperfusion using both a modified reperfusate and white blood cell filter results in complete preservation of pulmonary function. We therefore believe surgeons should control the reperfusate after lung transplantation to improve postoperative pulmonary function.
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Affiliation(s)
- A Halldorsson
- The Division of Cardiothoracic Surgery at the University of Illinois at Chicago, 60612, USA
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Bhabra MS, Hopkinson DN, Shaw TE, Onwu N, Hooper TL. Controlled reperfusion protects lung grafts during a transient early increase in permeability. Ann Thorac Surg 1998; 65:187-92. [PMID: 9456115 DOI: 10.1016/s0003-4975(97)01002-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND We have previously shown that an initial 10-minute period of low-pressure reperfusion prevents the lung graft dysfunction that follows physiologic-pressure reperfusion. Possible mechanisms were investigated in this study. METHODS Rat lungs were reperfused ex vivo using a parabiotic animal after 0-hour (groups A through C) or 24-hour (groups D through G) storage. Reperfusion pressure was either physiologic (groups A through D) or reduced by 50% for a specified time (groups E through G). The duration of reperfusion was 5 minutes (groups A, D, and E), 10 minutes (groups B and F), or 30 minutes (groups C and G), at which time endothelial permeability was measured through iodine 125-labeled albumin leakage and neutrophil sequestration through tissue myeloperoxidase activity. RESULTS Graft function in group D deteriorated rapidly, whereas groups E through G performed at control levels. Albumin leakage was significantly elevated in group D; with controlled reperfusion, it was elevated after 5 minutes (group E) but had returned to baseline at 10 minutes (group F) and 30 minutes (group G). Myeloperoxidase levels were not significantly different between groups. CONCLUSIONS Endothelial permeability is transiently elevated in the early phase of lung graft reperfusion. Initial low-pressure reperfusion may be protective by preventing irreversible edema formation during this period.
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Affiliation(s)
- M S Bhabra
- Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, United Kingdom
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Bhabra MS, Hopkinson DN, Shaw TE, Hooper TL. Low-dose nitric oxide inhalation during initial reperfusion enhances rat lung graft function. Ann Thorac Surg 1997; 63:339-44. [PMID: 9033297 DOI: 10.1016/s0003-4975(96)01019-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND In ischemia-reperfusion injury, the production of nitric oxide by dysfunctional endothelium falls rapidly within minutes of the onset of reperfusion. Replenishment during this critical early period using inhaled nitric oxide may benefit lung grafts through modulation of vascular tone, endothelial permeability, neutrophil and platelet function, and availability of reactive oxygen species. METHODS Rat lung grafts were flushed with 60 mL/kg cold University of Wisconsin solution and were reperfused either immediately (group I, n = 5) or after 24-hour 4 degrees C storage (groups II and III, n = 5 each), for 60 minutes in an ex vivo model incorporating a support animal. Graft ventilation was with room air. In group III, 20 parts per million inhaled nitric oxide was added during the initial 10 minutes of reperfusion, whereas in groups I and II, equivalent flows of nitrogen were added to standardize oxygen concentration. RESULTS Compared with group I, graft function in group II was poor, with reductions in oxygenation and blood flow and elevations of mean pulmonary artery pressure, peak airway pressure, and wet to dry weight ratio. In contrast, during nitric oxide inhalation in group III, graft function improved to control levels. This improvement was subsequently sustained throughout the reperfusion period. CONCLUSIONS Low-dose inhaled nitric oxide administration in the early phase of reperfusion of stored lung grafts can yield sustained improvement in function. There may be a role for inhaled nitric oxide in the prevention of reperfusion injury in transplanted lungs.
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Affiliation(s)
- M S Bhabra
- Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, United Kingdom
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Bhabra MS, Hopkinson DN, Shaw TE, Hooper TL. Attenuation of lung graft reperfusion injury by a nitric oxide donor. J Thorac Cardiovasc Surg 1997; 113:327-33; discussion 333-4. [PMID: 9040627 DOI: 10.1016/s0022-5223(97)70330-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE One of the primary features of ischemia-reperfusion injury is reduced production of protective autocoids, such as nitric oxide, by dysfunctional endothelium. Administration of a nitric oxide donor during reperfusion of lung grafts may therefore be beneficial through modulation of vascular tone and leukocyte and platelet function. METHODS Rat lung grafts were flushed with University of Wisconsin solution and reperfused for 1 hour in an ex vivo model incorporating a support animal. Group I grafts (n = 6) were reperfused immediately after explantation, group II (n = 6) and III (n = 5) grafts after 24 hours of storage at 4 degrees C. In group III, glyceryl trinitrate, a nitric oxide donor, was administered during the first 10 minutes of reperfusion at a rate of 200 micrograms/min. In an additional group (n = 5), 200 micrograms/min hydralazine was administered instead, to assess the effect of vasodilation alone. RESULTS Graft function in group II deteriorated compared with that in group I, with significant reduction of graft effluent oxygen tension and blood flow and elevation of pulmonary artery pressure, peak airway pressure, and wet/dry weight ratio. In contrast, in group III, glyceryl trinitrate treatment improved graft function to baseline levels in all these parameters. Administration of hydralazine, meanwhile, produced mixed results with only two out of five grafts functioning at control levels. CONCLUSIONS In this model, administration of glyceryl trinitrate to supplement the nitric oxide pathway in the early phase of reperfusion has a sustained beneficial effect on lung graft function after 24-hour hypothermic storage, probably through mechanisms beyond vasodilation alone.
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Affiliation(s)
- M S Bhabra
- Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, United Kingdom
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Bhabra MS, Hopkinson DN, Shaw TE, Hooper TL. Relative importance of prostaglandin/cyclic adenosine monophosphate and nitric oxide/cyclic guanosine monophosphate pathways in lung preservation. Ann Thorac Surg 1996; 62:1494-9. [PMID: 8893590 DOI: 10.1016/0003-4975(96)00498-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Modulation of vascular tone and platelet and neutrophil function through the prostaglandin/cyclic adenosine monophosphate or nitric oxide/cyclic guanosine monophosphate pathway can benefit lung graft function. The relative importance of these pathways is unclear. METHODS Rat lung grafts (5 per group) were studied in an ex vivo reperfusion model. Group I grafts were pretreated with prostacyclin (20 ng.kg-1.min-1), flushed with cold Euro-Collins solution containing prostacyclin (200 micrograms/L), and reperfused immediately for 1 hour. Group II grafts were similarly procured but were stored at 4 degrees C for 6 hours before reperfusion. In group III, no prostacyclin therapy was used; instead, the nitric oxide donor glyceryl trinitrate (0.1 mg/mL) was added to the flush/storage solution, and the grafts were stored for 6 hours. RESULTS Group II grafts performed poorly compared with those in group I, with substantial deterioration of oxygenation and blood flow and elevation of pulmonary artery pressure, peak airway pressure, and wet to dry weight ratio. In contrast, graft function in group III was similar to that in controls. CONCLUSIONS Lung graft integrity after storage in Euro-Collins solution was better preserved by glyceryl trinitrate than by prostacyclin in this model.
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Affiliation(s)
- M S Bhabra
- Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, United Kingdom
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