1
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Fumagalli J, Punzi V, Scaravilli V, Passamonti SM, Morlacchi LC, Rossetti V, Maraschini A, Matinato C, Brivio M, Righi I, Blasi F, Bandera A, Rosso L, Panigada M, Zanella A, Grasselli G. Lung donor bronchoalveolar lavage positivity: Incidence, risk factors, and lung transplant recipients' outcome. J Heart Lung Transplant 2024:S1053-2498(24)01566-3. [PMID: 38677352 DOI: 10.1016/j.healun.2024.04.005] [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: 01/22/2024] [Revised: 04/05/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Inconsistent data exists regarding the risk factors for bronchoalveolar lavage (BAL) positivity in lung donors, the incidence of donor-derived infections (DDI), and the effect of BAL positivity on lung transplant (LuTx) recipients' outcome. METHODS A retrospective analysis was conducted on consecutive LuTx at a single center from January 2016 to December 2022. Donors' data, including characteristics, graft function and BAL samples were collected pre-procurement. Recipients underwent BAL before LuTx and about the 3rd, 7th and 14th day after LuTx. A DDI was defined as BAL positivity (bacterial growth ≥104 colony forming units) for identical bacterial species between donor and recipient. Recipients' pre-operative characteristics, intra-operative management, and post-operative outcomes were assessed. Two recipient cohorts were identified based on lung colonization status before undergoing LuTx. RESULTS Out of 188 LuTx procedures performed, 169 were analyzed. Thirty-six percent of donors' BAL tested positive. Donors' characteristics and graft function at procurement were not associated with BAL positivity. Fourteen DDI were detected accounting for 23% of recipients receiving a graft with a positive BAL. Only among uncolonized recipients, receiving a graft with positive BAL is associated with higher likelihood of requiring invasive ventilation at 72 hours after LuTx on higher positive end-expiratory pressure levels having lower PaO2/FiO2, prolonged duration of mechanical ventilation and longer ICU stay. No difference in hospital length of stay was observed. CONCLUSIONS Receiving a graft with a positive BAL, which is poorly predicted by donors' characteristics, carries the risk of developing a DDI and is associated to a worse early graft function among uncolonized recipients.
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Affiliation(s)
- Jacopo Fumagalli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Veronica Punzi
- Dipartimento of Anesthesia, Critical Care, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Biomedical, Surgical, and Dental Sciences, University of Milan, Milan, Italy
| | - Serena M Passamonti
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Letizia C Morlacchi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda -Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Rossetti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda -Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Maraschini
- Microbiology Laboratory, Clinical Laboratory, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Caterina Matinato
- Microbiology Laboratory, Clinical Laboratory, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Margherita Brivio
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Righi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda -Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Bandera
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Infectious Diseases Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Rosso
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Mauro Panigada
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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2
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Hatami S, Conway J, Freed DH, Urschel S. Thoracic organ donation after circulatory determination of death. TRANSPLANTATION REPORTS 2023. [DOI: 10.1016/j.tpr.2022.100125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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3
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Noda K, Chan EG, Furukawa M, Ryan JP, Clifford S, Luketich JD, Sanchez PG. Single-center experience of ex vivo lung perfusion and subsequent lung transplantation. Clin Transplant 2023; 37:e14901. [PMID: 36588340 DOI: 10.1111/ctr.14901] [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: 09/30/2022] [Revised: 12/21/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND The safety of lung transplantation using ex vivo lung perfusion (EVLP) has been confirmed in multiple clinical studies; however, limited evidence is currently available regarding the potential effects of EVLP on posttransplant graft complications and survival with mid- to long-term follow-up. In this study, we reviewed our institutional data to better understand the impact of EVLP. METHODS Lungs placed on EVLP from 2014 through 2020 and transplant outcomes were retrospectively analyzed. Data were compared between lungs transplanted and declined after EVLP, between patients with severe primary graft dysfunction (PGD3) and no PGD3 after EVLP, and between matched patients with lungs transplanted with and without EVLP. RESULTS In total, 98 EVLP cases were performed. Changes in metabolic indicators during EVLP were correlated with graft quality and transplantability, but not changes in physiological parameters. Among 58 transplanted lungs after EVLP, PGD3 at 72 h occurred in 36.9% and was associated with preservation time, mechanical support prior to transplant, and intraoperative transfusion volume. Compared with patients without EVLP, patients who received lungs screened with EVLP had a higher incidence of PGD3 and longer ICU and hospital stays. Lung grafts placed on EVLP exhibited a significantly higher chance of developing airway anastomotic ischemic injury by 30 days posttransplant. Acute and chronic graft rejection, pulmonary function, and posttransplant survival were not different between patients with lungs screened on EVLP versus lungs with no EVLP. CONCLUSION EVLP use is associated with an increase of early posttransplant adverse events, but graft functional outcomes and patient survival are preserved.
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Affiliation(s)
- Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Masashi Furukawa
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John P Ryan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah Clifford
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James D Luketich
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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4
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Lee ACH, Edobor A, Wigakumar T, Lysandrou M, Johnston LK, McMullen P, Mirle V, Diaz A, Piech R, Rose R, Jendrisak M, di Sabato D, Shanmugarajah K, Fung J, Donington J, Madariaga ML. Donor leukocyte trafficking during human ex vivo lung perfusion. Clin Transplant 2022; 36:e14670. [PMID: 35396887 PMCID: PMC9540615 DOI: 10.1111/ctr.14670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/09/2022] [Accepted: 04/04/2022] [Indexed: 11/30/2022]
Abstract
Background Ex vivo lung perfusion (EVLP) is used to assess and preserve lungs prior to transplantation. However, its inherent immunomodulatory effects are not completely understood. We examine perfusate and tissue compartments to determine the change in immune cell composition in human lungs maintained on EVLP. Methods Six human lungs unsuitable for transplantation underwent EVLP. Tissue and perfusate samples were obtained during cold storage and at 1‐, 3‐ and 6‐h during perfusion. Flow cytometry, immunohistochemistry, and bead‐based immunoassays were used to measure leukocyte composition and cytokines. Mean values between baseline and time points were compared by Student's t test. Results During the 1st hour of perfusion, perfusate neutrophils increased (+22.2 ± 13.5%, p < 0.05), monocytes decreased (−77.5 ± 8.6%, p < 0.01) and NK cells decreased (−61.5 ± 22.6%, p < 0.01) compared to cold storage. In contrast, tissue neutrophils decreased (−22.1 ± 12.2%, p < 0.05) with no change in monocytes and NK cells. By 6 h, perfusate neutrophils, NK cells, and tissue neutrophils were similar to baseline. Perfusate monocytes remained decreased, while tissue monocytes remained unchanged. There was no significant change in B cells or T cell subsets. Pro‐inflammatory cytokines (IL‐1b, G‐CSF, IFN‐gamma, CXCL2, CXCL1 granzyme A, and granzyme B) and lymphocyte activating cytokines (IL‐2, IL‐4, IL‐6, IL‐8) increased during perfusion. Conclusions Early mobilization of innate immune cells occurs in both perfusate and tissue compartments during EVLP, with neutrophils and NK cells returning to baseline and monocytes remaining depleted after 6 h. The immunomodulatory effect of EVLP may provide a therapeutic window to decrease the immunogenicity of lungs prior to transplantation.
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Affiliation(s)
| | - Arianna Edobor
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - Maria Lysandrou
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Laura K Johnston
- Office of Shared Research Facilities, University of Chicago, Chicago, Illinois, USA
| | - Phillip McMullen
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Vikranth Mirle
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ashley Diaz
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ryan Piech
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Rebecca Rose
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - Diego di Sabato
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - John Fung
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Jessica Donington
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
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5
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Ischemia-Reperfusion Injury in Lung Transplantation. Cells 2021; 10:cells10061333. [PMID: 34071255 PMCID: PMC8228304 DOI: 10.3390/cells10061333] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 02/08/2023] Open
Abstract
Lung transplantation has been established worldwide as the last treatment for end-stage respiratory failure. However, ischemia–reperfusion injury (IRI) inevitably occurs after lung transplantation. The most severe form of IRI leads to primary graft failure, which is an important cause of morbidity and mortality after lung transplantation. IRI may also induce rejection, which is the main cause of mortality in recipients. Despite advances in donor management and graft preservation, most donor grafts are still unsuitable for transplantation. Although the pulmonary endothelium is the primary target site of IRI, the pathophysiology of lung IRI remains incompletely understood. It is essential to understand the mechanism of pulmonary IRI to improve the outcomes of lung transplantation. Therefore, we reviewed the state-of-the-art in the management of pulmonary IRI after lung transplantation. Recently, the ex vivo lung perfusion (EVLP) system has been clinically introduced worldwide. Various promising therapeutic strategies for the protection of the endothelium against IRI, including EVLP, inhalation therapy with therapeutic gases and substances, fibrinolytic treatment, and mesenchymal stromal cell therapy, are awaiting clinical application. We herein review the latest advances in the field of pulmonary IRI in lung transplantation.
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6
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Nakajima D, Date H. Ex vivo lung perfusion in lung transplantation. Gen Thorac Cardiovasc Surg 2021; 69:625-630. [PMID: 33683575 PMCID: PMC7938286 DOI: 10.1007/s11748-021-01609-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/17/2021] [Indexed: 01/08/2023]
Abstract
Lung transplantation is an established life-saving intervention for patients with end-stage lung diseases. The success of lung transplantation mainly depends on the quality and function of the implanted donor lungs, which are frequently subject to brain-death-induced lung injuries and intensive care unit (ICU)-related complications before transplantation. Recent innovations, particularly the development of ex vivo lung perfusion (EVLP), in which donor lungs are ventilated and perfused under normothermic conditions outside the body, have allowed clinicians to more accurately assess the donor lung function prior to transplantation. Therefore, EVLP has been successfully translated into clinical practice with the expansion of the donor lung pool, leading to favorable post-transplant outcomes in a growing number of transplant centers worldwide. The EVLP system and techniques, following the Toronto protocol, have recently been applied for the assessment of extended criteria brain-death donors in clinical lung transplantation in Japan. The advancement of EVLP from organ assessment to organ treatment will be the next challenging stage not only to expand donor lung pool, but also to improve graft survival and long-term outcomes after transplantation.
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Affiliation(s)
- Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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7
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HSP90 Inhibitor Improves Lung Protection in Porcine Model of Donation After Circulatory Arrest. Ann Thorac Surg 2020; 110:1861-1868. [PMID: 32652069 DOI: 10.1016/j.athoracsur.2020.05.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/24/2020] [Accepted: 05/11/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Ischemia-reperfusion associated with prolonged warm ischemia during donation after circulatory death (DCD) induces acute lung injury. The objective of this study was to combine ex vivo lung perfusion (EVLP) and a heat shock protein-90 inhibitor (HSP90i) to recondition DCD organs and prevent primary graft dysfunction. METHODS Pigs (55 to 65 kg) were anesthetized, ventilated, and hemodynamically monitored. Cardiac arrest was induced with potassium chloride, and animals were left nonventilated for 2 hours. Lungs were procured and perfused in an EVLP platform for 4 hours by using a cellular perfusate. In the study group, the perfusate contained HSP90i and its transport vehicle (n = 4). In the control group, the perfusate contained only the transport vehicle (n = 4). Gas exchange, airway pressures, and compliance were measured. Pulmonary edema was assessed by bronchoscopy and weight measurement. Lung biopsy samples were obtained for histologic analyses and protein expression measurements. RESULTS The use of HSP90i reduced lung weight gain to 8.4 ± 3.4% vs 26.6 ± 6.2% in the control group (P < .05). There was reduced edema formation. The ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen at the end of EVLP was 423 ± 65 in the study group vs 339 ± 25 mm Hg in the control group, but this difference was not statistically significant. Lactate metabolism, pulmonary vascular resistance, and pulmonary arterial pressure improved during EVLP with the use of the HSP90i. CONCLUSIONS The use of HSP90i with EVLP improves the lung reconditioning process. Further research is required to confirm whether these findings translate to benefit once transplanted and observed in vivo. Successful pharmacologic inhibitors may expand the donor pool in the context of DCD donors.
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8
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Hyperinflation With Pulmonary Dysfunction in Donor Lungs With Smoking History During Lung Perfusion. J Surg Res 2020; 255:502-509. [PMID: 32622165 DOI: 10.1016/j.jss.2020.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/31/2020] [Accepted: 05/06/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Donor lungs with smoking history are perfused in ex vivo lung perfusion (EVLP) to expand donor lung pool. However, the impact of hyperinflation of perfused lungs in EVLP remains unknown. The aim of this study was to investigate the significance of hyperinflation, using an ex vivo measurement delta VT, during EVLP in smoker's lungs. MATERIALS AND METHODS Seventeen rejected donor lungs with smoking history of median 10 pack-years were perfused for 2 h in cellular EVLP. Hyperinflation was evaluated by measuring delta VT = inspiratory - expiratory tidal volume (VT) difference at 1 h. All lungs were divided into two groups; negative delta VT (n = 11, no air-trapping pattern) and positive delta VT (n = 6, air-trapping pattern). Transplant suitability was judged at 2 h. By using lung tissue, linear intercept analysis was performed to evaluate the degree of hyperinflation. RESULTS The positive delta VT group had significantly lower transplant suitability than the negative delta VT group (16 versus 81%, P = 0.035). The positive delta VT group was significantly associated with lower partial pressure of oxygen/fraction of inspired oxygen ratio ratio (278 versus 356 mm Hg, P = 0.049), higher static compliance (119 versus 98 mL/cm H2O, P = 0.050), higher lung weight ratio (1.10 versus 0.96, P = 0.014), and higher linear intercept ratio (1.52 versus 0.93, P = 0.005) than the negative delta VT group. CONCLUSIONS Positive delta VT appears as an ex vivo marker of ventilator-associated lung hyperinflation of smoker's lungs during EVLP.
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9
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Fumagalli J, Rosso L, Gori F, Morlacchi LC, Rossetti V, Tarsia P, Blasi F, Righi I, Mendogni P, Palleschi A, Tosi D, Bonitta G, Nosotti M, Benazzi E, Scaravilli V, Valenza F, Grasselli G, Zanella A. Early pulmonary function and mid-term outcome in lung transplantation after ex-vivo lung perfusion - a single-center, retrospective, observational, cohort study. Transpl Int 2020; 33:773-785. [PMID: 32219887 DOI: 10.1111/tri.13606] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/20/2020] [Accepted: 03/16/2020] [Indexed: 12/14/2022]
Abstract
Outcomes after transplantation of lungs (LuTX) treated with ex-vivo lung perfusion (EVLP) are debated. In a single-center 8 years of retrospective analysis, we compared: donors' and recipients' characteristics, gas exchange and lung mechanics at ICU admission, 3, 6, and 12 months, and patients' survival of LuTX from standard donors compared with EVLP-treated grafts. A total of 193 LuTX were performed. Thirty-one LuTX, out of 50 EVLP procedures, were carried out: 7 from nonheart beating and 24 from extended criteria brain-dead donors. Recipients' characteristics were similar. At ICU admission, compared with standard donors, EVLP patients had worse PaO2 /FiO2 [276 (206; 374) vs. 204 (133; 245) mmHg, P < 0.05], more frequent extracorporeal support (18% vs. 32%, P = 0.053) and longer mechanical ventilation duration [28 days of ventilator-free days: 27 (24; 28) vs. 26 (19; 27), P < 0.05]. ICU length of stay [4 (2; 9) vs. 6 (3; 12) days, P = 0.208], 28-day survival (99% vs. 97%, P = 0.735), and 1-year respiratory function were similar between groups. Log-rank analysis (median follow-up 2.5 years) demonstrated similar patients' survival (P = 0.439) and time free of chronic lung allograft disease (P = 0.484). The EVLP program increased by 16% the number of LuTX. Compared to standard donors, EVLP patients had worse respiratory function immediately after LuTX but similar early and mid-term outcomes.
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Affiliation(s)
- Jacopo Fumagalli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Rosso
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Francesca Gori
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Letizia Corinna Morlacchi
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Rossetti
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Tarsia
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Righi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Mendogni
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Palleschi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Tosi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluca Bonitta
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Elena Benazzi
- Coordinamento Trapianti North Italy Transplantation Program (NITp), Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Franco Valenza
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesia and Critical Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Wang X, Parapanov R, Debonneville A, Wang Y, Abdelnour-Berchtold E, Gonzalez M, Gronchi F, Perentes JY, Ris HB, Eckert P, Piquilloud L, Lugrin J, Letovanec I, Krueger T, Liaudet L. Treatment with 3-aminobenzamide during ex vivo lung perfusion of damaged rat lungs reduces graft injury and dysfunction after transplantation. Am J Transplant 2020; 20:967-976. [PMID: 31710417 DOI: 10.1111/ajt.15695] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 01/25/2023]
Abstract
Ex vivo lung perfusion (EVLP) with pharmacological reconditioning may increase donor lung utilization for transplantation (LTx). 3-Aminobenzamide (3-AB), an inhibitor of poly(ADP-ribose) polymerase (PARP), reduces ex vivo lung injury in rat lungs damaged by warm ischemia (WI). Here we determined the effects of 3-AB reconditioning on graft outcome after LTx. Three groups of donor lungs were studied: Control (Ctrl): 1 hour WI + 3 hours cold ischemia (CI) + LTx; EVLP: 1 hour WI + 3 hours EVLP + LTx; EVLP + 3-AB: 1 hour WI + 3 hours EVLP + 3-AB (1 mg. mL-1 ) + LTx. Two hours after LTx, we determined lung graft compliance, edema, histology, neutrophil counts in bronchoalveolar lavage (BAL), mRNA levels of adhesion molecules within the graft, as well as concentrations of interleukin-6 and 10 (IL-6, IL-10) in BAL and plasma. 3-AB reconditioning during EVLP improved compliance and reduced lung edema, neutrophil infiltration, and the expression of adhesion molecules within the transplanted lungs. 3-AB also attenuated the IL-6/IL-10 ratio in BAL and plasma, supporting an improved balance between pro- and anti-inflammatory mediators. Thus, 3-AB reconditioning during EVLP of rat lung grafts damaged by WI markedly reduces inflammation, edema, and physiological deterioration after LTx, supporting the use of PARP inhibitors for the rehabilitation of damaged lungs during EVLP.
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Affiliation(s)
- Xingyu Wang
- Service of Thoracic Surgery, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Roumen Parapanov
- Service of Thoracic Surgery, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland.,Service of Adult Intensive Care Medicine, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Anne Debonneville
- Service of Thoracic Surgery, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Yabo Wang
- Service of Thoracic Surgery, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Etienne Abdelnour-Berchtold
- Service of Thoracic Surgery, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Michel Gonzalez
- Service of Thoracic Surgery, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Fabrizio Gronchi
- Service of Anesthesiology, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Jean-Yannis Perentes
- Service of Thoracic Surgery, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Hans-Beat Ris
- Service of Thoracic Surgery, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Philippe Eckert
- Service of Adult Intensive Care Medicine, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Lise Piquilloud
- Service of Adult Intensive Care Medicine, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Jérôme Lugrin
- Service of Adult Intensive Care Medicine, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Igor Letovanec
- Faculty of Biology and Medicine, The University Institute of Pathology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Thorsten Krueger
- Service of Thoracic Surgery, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Lucas Liaudet
- Service of Adult Intensive Care Medicine, Faculty of Biology and Medicine, University Hospital of Lausanne, Lausanne, Switzerland
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Increased Arginase Expression and Decreased Nitric Oxide in Pig Donor Lungs after Normothermic Ex Vivo Lung Perfusion. Biomolecules 2020; 10:biom10020300. [PMID: 32075026 PMCID: PMC7072555 DOI: 10.3390/biom10020300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/30/2020] [Accepted: 02/11/2020] [Indexed: 01/12/2023] Open
Abstract
An established pig lung transplantation model was used to study the effects of cold ischemia time, normothermic acellular ex vivo lung perfusion (EVLP) and reperfusion after lung transplantation on l-arginine/NO metabolism in lung tissue. Lung tissue homogenates were analyzed for NO metabolite (NOx) concentrations by chemiluminescent NO-analyzer technique, and l-arginine, l-ornithine, l-citrulline and asymmetric dimethylarginine (ADMA) quantified using liquid chromatography-mass spectrometry (LC-MS/MS). The expression of arginase and nitric oxide synthase (NOS) isoforms in lung was measured by real-time polymerase chain reaction. EVLP preservation resulted in a significant decrease in concentrations of NOx and l-citrulline, both products of NOS, at the end of EVLP and after reperfusion following transplantation, compared to control, respectively. The ratio of l-ornithine over l-citrulline, a marker of the balance between l-arginine metabolizing enzymes, was increased in the EVLP group prior to reperfusion. The expression of both arginase isoforms was increased from baseline 1 h post reperfusion in EVLP but not in the no-EVLP group. These data suggest that EVLP results in a shift of the l-arginine balance towards arginase, leading to NO deficiency in the lung. The arginase/NOS balance may, therefore, represent a therapeutic target to improve lung quality during EVLP and, subsequently, transplant outcomes.
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Structure and Function of Porcine Arteries Are Preserved for up to 6 Days Using the HypoRP Cold-storage Solution. Transplantation 2020; 104:e125-e134. [PMID: 32000259 DOI: 10.1097/tp.0000000000003141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Maintaining functional vessels during preservation of vascularized composite allografts (VCAs) remains a major challenge. The University of Wisconsin (UW) solution has demonstrated significant short-term benefits (4-6 h). Here we determined whether the new hypothermic resuscitation and preservation solution HypoRP improves both structure, survival, and function of pig arteries during storage for up to 6 days. METHODS Using porcine swine mesenteric arteries, the effects of up to 6-day incubation in a saline (PBS), UW, or HypoRP solution on the structure, cell viability, metabolism, and function were determined. RESULTS After incubation at 4°C, for up to 6 days, the structures of the arteries were significantly disrupted, especially the tunica media, following incubation in PBS, in contrast with incubation in the HypoRP solution and to a lesser extent, in UW solution. Those disruptions were associated with increased active caspase 3 indicative of apoptosis. Additionally, while incubation in PBS led to a significant decrease in the metabolic activity, UW and HypoRP solutions allowed a stable to increased metabolic activity following 6 days of cold storage. Functional responsiveness to phenylephrine (PE) and sodium nitroprusside (SNP) decreased over time for artery rings stored in PBS and UW solution but not for those stored in HypoRP solution. Moreover, artery rings cold-stored in HypoRP solution were more sensitive to ATP. CONCLUSIONS The HypoRP solution improved long-term cold storage of porcine arteries by limiting structural alterations, including the collagen matrix, reducing apoptosis, and maintaining artery contraction-relaxation functions for up to 6 days.
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Ghaidan H, Fakhro M, Andreasson J, Pierre L, Ingemansson R, Lindstedt S. Ten year follow-up of lung transplantations using initially rejected donor lungs after reconditioning using ex vivo lung perfusion. J Cardiothorac Surg 2019; 14:125. [PMID: 31262311 PMCID: PMC6604441 DOI: 10.1186/s13019-019-0948-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 06/24/2019] [Indexed: 02/03/2023] Open
Abstract
Background In 2006 and 2007 we performed double lung transplantation with marginal donor lungs assessed and reconditioned by Ex Vivo Lung Perfusion (EVLP), using a technique developed by Professor Stig Steen. Here we present a 10-year follow-up comparing the outcomes of lung transplantations performed at our clinic using EVLP lungs vs. conventional lungs. Method Between 2006 and 2007, 21 patients (6 EVLP, 15 conventional) underwent double lung transplantation (LTx) with follow-up on May 2017 at Lund University Hospital, Sweden. Pulmonary function was measured at 3/6/12 months, and annually thereafter for a period of 10 years in addition to survival and freedom from chronic lung allograft dysfunction (CLAD) being analyzed. Results Regarding Forced Expiratory Volume in 1 s (FEV1) and 6MWT at 3, 6, and 12 months and annually thereafter, no difference in median FEV1 nor 6MWT was found for EVLP-LTx vs. conventional-LTx (p > 0.05). No difference was shown in post-operative survival between EVLP-LTx vs. conventional LTx for patients with an overall survival up to 10-years (p > 0.05). The same pattern was shown in sub analyses for patients with a limited survival up to 1 and 5 years (p > 0.05). Conclusion No superiority was found in conventional-LTx over EVLP-LTx, neither in long-term survival nor pulmonary function. No difference in CLAD-free survival was seen between the two groups. We believe that EVLP is a safe and effective method to use in LTx, greatly increasing the donor pool by improving marginal lungs and providing an objective assessment of the viability of marginal donor lungs.
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Affiliation(s)
- Haider Ghaidan
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Mohammed Fakhro
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jesper Andreasson
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Leif Pierre
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Richard Ingemansson
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden. .,Wallenberg Center for Molecular Medicine, Lund University, 221 85, Lund, Sweden.
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Endothelial Glycocalyx Shedding Predicts Donor Organ Acceptability and Is Associated With Primary Graft Dysfunction in Lung Transplant Recipients. Transplantation 2019; 103:1277-1285. [DOI: 10.1097/tp.0000000000002539] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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15
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Ex Vivo Assessment of Porcine Donation After Circulatory Death Lungs That Undergo Increasing Warm Ischemia Times. Transplant Direct 2018; 4:e405. [PMID: 30584586 PMCID: PMC6283086 DOI: 10.1097/txd.0000000000000845] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 10/07/2018] [Indexed: 01/11/2023] Open
Abstract
Background Increased utilization of donation after circulatory death (DCD) lungs may help alleviate the supply/demand mismatch between available donor organs and lung transplant candidates. Using an established porcine DCD model, we sought to determine the effect of increasing warm ischemia time (WIT) after circulatory arrest on lung function during ex vivo lung perfusion (EVLP). Methods Porcine donors (n = 15) underwent hypoxic cardiac arrest, followed by 60, 90, or 120 minutes of WIT before procurement and 4 hours of normothermic EVLP. Oxygenation, pulmonary artery pressure, airway pressure, and compliance were measured hourly. Lung injury scores were assessed histologically after 4 hours of EVLP. Results After EVLP, all 3 groups met all the criteria for transplantation, except for 90-minute WIT lungs, which had a mean pulmonary artery pressure increase greater than 15%. There were no significant differences between groups as assessed by final oxygenation capacity, as well as changes in pulmonary artery pressure, airway pressure, or lung compliance. Histologic lung injury scores as well as lung wet-to-dry weight ratios did not significantly differ between groups. Conclusions These results suggest that longer WIT alone (up to 120 minutes) does not predict worse lung function at the conclusion of EVLP. Expanding acceptable WIT after circulatory death may eventually allow for increased utilization of DCD lungs in procurement protocols.
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16
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Targeting Circulating Leukocytes and Pyroptosis During Ex Vivo Lung Perfusion Improves Lung Preservation. Transplantation 2017; 101:2841-2849. [DOI: 10.1097/tp.0000000000001798] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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17
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Spratt JR, Mattison LM, Iaizzo PA, Brown RZ, Helms H, Iles TL, Howard B, Panoskaltsis-Mortari A, Loor G. An experimental study of the recovery of injured porcine lungs with prolonged normothermic cellularex vivolung perfusion following donation after circulatory death. Transpl Int 2017; 30:932-944. [DOI: 10.1111/tri.12981] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 03/31/2017] [Accepted: 05/05/2017] [Indexed: 12/14/2022]
Affiliation(s)
- John R. Spratt
- Department of Surgery; University of Minnesota; Minneapolis MN USA
| | - Lars M. Mattison
- Department of Surgery; University of Minnesota; Minneapolis MN USA
- Department of Biomedical Engineering; University of Minnesota; Minneapolis MN USA
| | - Paul A. Iaizzo
- Department of Surgery; University of Minnesota; Minneapolis MN USA
- Department of Biomedical Engineering; University of Minnesota; Minneapolis MN USA
- Department of Integrative Biology and Physiology; University of Minnesota; Minneapolis MN USA
- Institute for Engineering in Medicine; University of Minnesota; Minneapolis MN USA
| | - Roland Z. Brown
- Division of Biostatistics; University of Minnesota; Minneapolis MN USA
| | - Haylie Helms
- Department of Pediatrics; University of Minnesota; Minneapolis MN USA
- Department of Medicine; University of Minnesota; Minneapolis MN USA
- Masonic Cancer Center; University of Minnesota; Minneapolis MN USA
| | - Tinen L. Iles
- Department of Surgery; University of Minnesota; Minneapolis MN USA
- Department of Biomedical Engineering; University of Minnesota; Minneapolis MN USA
| | - Brian Howard
- Department of Surgery; University of Minnesota; Minneapolis MN USA
- Department of Biomedical Engineering; University of Minnesota; Minneapolis MN USA
| | - Angela Panoskaltsis-Mortari
- Department of Pediatrics; University of Minnesota; Minneapolis MN USA
- Department of Medicine; University of Minnesota; Minneapolis MN USA
- Masonic Cancer Center; University of Minnesota; Minneapolis MN USA
| | - Gabriel Loor
- Division of Cardiothoracic Surgery; Department of Surgery; University of Minnesota; Minneapolis MN USA
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Pharmacological Reconditioning of Marginal Donor Rat Lungs Using Inhibitors of Peroxynitrite and Poly (ADP-ribose) Polymerase During Ex Vivo Lung Perfusion. Transplantation 2017; 100:1465-73. [PMID: 27331361 DOI: 10.1097/tp.0000000000001183] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Donor lungs obtained after prolonged warm ischemia (WI) may be unsuitable for transplantation due to the risk of reperfusion injury, but could be reconditioned using ex-vivo lung perfusion (EVLP). Key processes of reperfusion injury include the formation of reactive oxygen species (ROS)/nitrogen species (RNS) and the activation of poly(adenosine diphosphate-ribose) polymerase (PARP). We explored whether rat lungs obtained after WI could be reconditioned during EVLP using the ROS/RNS scavenger Mn(III)-tetrakis (4-benzoic acid) porphyrin chloride (MnTBAP) or the PARP inhibitor 3-aminobenzamide (3-AB). METHODS Rat lungs obtained after 3 hours cold ischemia (CI group, control), or 1 hour WI plus 2 hours CI (WI group) were placed in an EVLP circuit for normothermic perfusion for 3 hours. Lungs retrieved after WI were treated or not with 3-AB (1 mg/mL) or MnTBAP (0.3 mg/mL), added to the perfusate. Measurements included physiological variables (lung compliance, vascular resistance, oxygenation capacity), lung weight gain, levels of proteins, lactate dehydrogenase, protein carbonyl (marker of ROS), 3-nitrotyrosine (marker of RNS), poly(adenosine diphosphate-ribose) (PAR, marker of PARP activation) and IL-6, in the bronchoalveolar lavage or the lung tissue, and histology. RESULTS In comparison to the CI group, the lungs from the WI group displayed higher protein carbonyls, 3-nitrotyrosine, PAR, lactate dehydrogenase and proteins in bronchoalveolar lavage, lung weight gain, perivascular edema, as well as reduced static compliance, but similar oxygenation. All these alterations were markedly attenuated by 3-AB and MnTBAP. CONCLUSIONS After EVLP, lungs obtained after WI exhibit oxidative stress, PARP activation, and tissue injury, which are suppressed by pharmacological inhibitors of ROS/RNS and PARP.
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Hijiya K, Chen-Yoshikawa TF, Kondo T, Motoyama H, Ohsumi A, Nakajima D, Sakamoto J, Ohata K, Takahashi M, Tanaka S, Miyamoto E, Aoyama A, Date H. Bronchodilator Inhalation During Ex Vivo Lung Perfusion Improves Posttransplant Graft Function After Warm Ischemia. Ann Thorac Surg 2017; 103:447-453. [DOI: 10.1016/j.athoracsur.2016.07.066] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/03/2016] [Accepted: 07/25/2016] [Indexed: 11/25/2022]
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20
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Valenza F, Citerio G, Palleschi A, Vargiolu A, Fakhr BS, Confalonieri A, Nosotti M, Gatti S, Ravasi S, Vesconi S, Pesenti A, Blasi F, Santambrogio L, Gattinoni L. Successful Transplantation of Lungs From an Uncontrolled Donor After Circulatory Death Preserved In Situ by Alveolar Recruitment Maneuvers and Assessed by Ex Vivo Lung Perfusion. Am J Transplant 2016; 16:1312-8. [PMID: 26603283 PMCID: PMC5021126 DOI: 10.1111/ajt.13612] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/16/2015] [Accepted: 10/14/2015] [Indexed: 01/25/2023]
Abstract
We developed a protocol to procure lungs from uncontrolled donors after circulatory determination of death (NCT02061462). Subjects with cardiovascular collapse, treated on scene by a resuscitation team and transferred to the emergency room, are considered potential donors once declared dead. Exclusion criteria include unwitnessed collapse, no-flow period of >15 min and low flow >60 min. After death, lung preservation with recruitment maneuvers, continuous positive airway pressure, and protective mechanical ventilation is applied to the donor. After procurement, ex vivo lung perfusion (EVLP) is performed. From November 2014, 10 subjects were considered potential donors; one of these underwent the full process of procurement, EVLP, and transplantation. The donor was a 46-year-old male who died because of thoracic aortic dissection. Lungs were procured 4 h and 48 min after death, and deemed suitable for transplantation after EVLP. Lungs were then offered to a rapidly deteriorating recipient with cystic fibrosis (lung allocation score [LAS] 46) who consented to the transplant in this experimental setting. Six months after transplantation, the recipient is in good condition (forced expiratory volume in 1 s 85%) with no signs of rejection. This protocol allowed procurement of lungs from an uncontrolled donor after circulatory determination of death following an extended period of warm ischemia.
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Affiliation(s)
- F. Valenza
- Dipartimento di Anestesia Rianimazione (Intensiva e Sub intensiva) e Terapia del doloreFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly,Dipartimento di Fisiopatologica Medico‐Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly
| | - G. Citerio
- Scuola di Medicina e ChirurgiaUniversità di Milano‐BicoccaMilanItaly,Dipartimento Anestesia e RianimazioneAzienda Ospedaliera San GerardoMonzaItaly
| | - A. Palleschi
- Unità Operativa di Chirurgia ToracicaFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - A. Vargiolu
- Dipartimento Anestesia e RianimazioneAzienda Ospedaliera San GerardoMonzaItaly
| | - B. Safaee Fakhr
- Dipartimento di Anestesia Rianimazione (Intensiva e Sub intensiva) e Terapia del doloreFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - A. Confalonieri
- Dipartimento Anestesia e RianimazioneAzienda Ospedaliera San GerardoMonzaItaly
| | - M. Nosotti
- Dipartimento di Fisiopatologica Medico‐Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly,Unità Operativa di Chirurgia ToracicaFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - S. Gatti
- Centro di Ricerche Chirurgiche PreclinicheFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - S. Ravasi
- Dipartimento Emergenza Urgenza–EASMilanItaly
| | - S. Vesconi
- Direzione Generale Salute LombardiaRegione LombardiaMilanItaly
| | - A. Pesenti
- Scuola di Medicina e ChirurgiaUniversità di Milano‐BicoccaMilanItaly,Dipartimento Anestesia e RianimazioneAzienda Ospedaliera San GerardoMonzaItaly
| | - F. Blasi
- Dipartimento di Fisiopatologica Medico‐Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly,Unità Operativa Complessa BroncopneumologiaFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - L. Santambrogio
- Dipartimento di Fisiopatologica Medico‐Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly,Unità Operativa di Chirurgia ToracicaFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - L. Gattinoni
- Dipartimento di Anestesia Rianimazione (Intensiva e Sub intensiva) e Terapia del doloreFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly,Dipartimento di Fisiopatologica Medico‐Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly
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21
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Ex vivo lung graft perfusion. Anaesth Crit Care Pain Med 2016; 35:123-31. [DOI: 10.1016/j.accpm.2015.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 09/25/2015] [Indexed: 01/08/2023]
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22
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Ex Vivo Perfusion With Adenosine A2A Receptor Agonist Enhances Rehabilitation of Murine Donor Lungs After Circulatory Death. Transplantation 2016; 99:2494-503. [PMID: 26262504 DOI: 10.1097/tp.0000000000000830] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) enables assessment and rehabilitation of marginal donor lungs before transplantation. We previously demonstrated that adenosine A2A receptor (A2AR) agonism attenuates lung ischemia-reperfusion injury. The current study utilizes a novel murine EVLP model to test the hypothesis that A2AR agonist enhances EVLP-mediated rehabilitation of donation after circulatory death (DCD) lungs. METHODS Mice underwent euthanasia and 60 minutes warm ischemia, and lungs were flushed with Perfadex and underwent cold static preservation (CSP, 60 minutes). Three groups were studied: no EVLP (CSP), EVLP with Steen solution for 60 minutes (EVLP), and EVLP with Steen solution supplemented with ATL1223, a selective A2AR agonist (EVLP + ATL1223). Lung function, wet/dry weight, cytokines and neutrophil numbers were measured. Microarrays were performed using the Affymetrix GeneChip Mouse Genome 430A 2.0 Array. RESULTS Ex vivo lung perfusion significantly improved lung function versus CSP, which was further, significantly improved by EVLP + ATL1223. Lung edema, cytokines, and neutrophil counts were reduced after EVLP and further, significantly reduced after EVLP + ATL1223. Gene array analysis revealed differential expression of 1594 genes after EVLP, which comprise canonical pathways involved in inflammation and innate immunity including IL-1, IL-8, IL-6, and IL-17 signaling. Several pathways were uniquely regulated by EVLP + ATL1223 including the downregulation of genes involved in IL-1 signaling, such as ADCY9, ECSIT, IRAK1, MAPK12, and TOLLIP. CONCLUSIONS Ex vivo lung perfusion modulates proinflammatory genes and reduces pulmonary dysfunction, edema, and inflammation in DCD lungs, which are further reduced by A2AR agonism. This murine EVLP model provides a novel platform to study rehabilitative mechanisms of DCD lungs.
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Abstract
PURPOSE OF REVIEW The number of patients listed for lung transplantation largely exceeds the number of available transplantable organs because of a shortage of organ donors and a low utilization rate of lungs from those donors who are available. In recent years, novel strategies have been developed to increase the donor lung pool: improved donor management, the use of lungs from donations after cardiac death (DCD), the use of lobar lung living-donors (LLLD) and the use of ex-vivo lung perfusion (EVLP) to assess and repair injured donor lungs. RECENT FINDINGS An adapted donor management strategy could expand the donor pool up to 20%. DCD lung transplant is an increasing part of the donor pool expansion. Outcomes after controlled DCD seem to be similar to donation after brain death. LLLD transplantation has excellent results for small and critically ill patients. EVLP treatment allows for a significant increase in the rate of suitable lungs and represents an optimal platform for lung reconditioning and specific lung therapies. SUMMARY A significant increase in the number of available lungs for transplantation is expected in the future because of the wider use of lungs from controlled or uncontrolled DCD and LLLD lungs, and with organ-specific EVLP treatment strategies.
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25
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Egan TM, Requard JJ. Uncontrolled Donation After Circulatory Determination of Death Donors (uDCDDs) as a Source of Lungs for Transplant. Am J Transplant 2015; 15:2031-6. [PMID: 25873272 PMCID: PMC5491386 DOI: 10.1111/ajt.13246] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 12/31/2014] [Accepted: 02/01/2015] [Indexed: 02/06/2023]
Abstract
In April 2014, the American Journal of Transplantation published a report on the first lung transplant in the United States recovered from an uncontrolled donation after circulatory determination of death donor (uDCDD), assessed by ex vivo lung perfusion (EVLP). The article identified logistical and ethical issues related to introduction of lung transplant from uDCDDs. In an open clinical trial, we have Food and Drug Administration and Institutional Review Board approval to transplant lungs recovered from uDCDDs judged suitable after EVLP. Through this project and other experiences with lung recovery from uDCDDs, we have identified solutions to many logistical challenges and have addressed ethical issues surrounding lung transplant from uDCDDs that were mentioned in this case report. Here, we discuss those challenges, including issues related to recovery of other solid organs from uDCDDs. Despite logistical challenges, uDCDDs could solve the critical shortage of lungs for transplant. Furthermore, by avoiding the deleterious impact of brain death and days of positive pressure ventilation, and by using opportunities to treat lungs in the decedent or during EVLP, lungs recovered from uDCDDs may ultimately prove to be better than lungs currently being transplanted from conventional brain-dead organ donors.
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Affiliation(s)
- T. M. Egan
- Division of Cardiothoracic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC,Corresponding author: Thomas M. Egan,
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26
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Machuca TN, Mercier O, Collaud S, Tikkanen J, Krueger T, Yeung JC, Chen M, Azad S, Singer L, Yasufuku K, de Perrot M, Pierre A, Waddell TK, Keshavjee S, Cypel M. Lung transplantation with donation after circulatory determination of death donors and the impact of ex vivo lung perfusion. Am J Transplant 2015; 15:993-1002. [PMID: 25772069 DOI: 10.1111/ajt.13124] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/28/2014] [Accepted: 10/29/2014] [Indexed: 01/25/2023]
Abstract
The growing demand for suitable lungs for transplantation drives the quest for alternative strategies to expand the donor pool. The aim of this study is to evaluate the outcomes of lung transplantation (LTx) with donation after circulatory determination of death (DCDD) and the impact of selective ex vivo lung perfusion (EVLP). From 2007 to 2013, 673 LTx were performed, with 62 (9.2%) of them using DCDDs (seven bridged cases). Cases bridged with mechanical ventilation/extracorporeal life support were excluded. From 55 DCDDs, 28 (51%) underwent EVLP. Outcomes for LTx using DCDDs and donation after neurological determination of death (DNDD) donors were similar, with 1 and 5-year survivals of 85% and 54% versus 86% and 62%, respectively (p = 0.43). Although comparison of survival curves between DCDD + EVLP versus DCDD-no EVLP showed no significant difference, DCDD + EVLP cases presented shorter hospital stay (median 18 vs. 23 days, p = 0.047) and a trend toward shorter length of mechanical ventilation (2 vs. 3 days, p = 0.059). DCDDs represent a valuable source of lungs for transplantation, providing similar results to DNDDs. EVLP seems an important technique in the armamentarium to safely increase lung utilization from DCDDs; however, further studies are necessary to better define the role of EVLP in this context.
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Affiliation(s)
- T N Machuca
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
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Popov AF, Sabashnikov A, Patil NP, Zeriouh M, Mohite PN, Zych B, Saez DG, Schmack B, Ruhparwar A, Dohmen PM, Karck M, Simon AR, Weymann A. Ex vivo lung perfusion - state of the art in lung donor pool expansion. Med Sci Monit Basic Res 2015; 21:9-14. [PMID: 25644463 PMCID: PMC4325829 DOI: 10.12659/msmbr.893674] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 01/26/2015] [Indexed: 11/11/2022] Open
Abstract
Lung transplantation remains the gold standard for patients with end-stage lung disease. Nevertheless, the number of suitable donor lungs for the increasing number of patients on the waiting list necessitates alternative tools to expand the lung donor pool. Modern preservation and lung assessment techniques could contribute to improved function in previously rejected lungs. Ex vivo lung perfusion (EVLP) already demonstrated its value in identification of transplantable grafts from the higher risk donor pool. Moreover, lungs from EVLP did not show significantly different postoperative results compared to standard criteria lungs. This could be explained by the reduction of the ischemia-reperfusion injury through EVLP application. The aim of this article is to review technical characteristics and the growing clinical EVLP experience with special attention to EVLP application for donation after cardiac death (DCD) lungs.
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Affiliation(s)
- Aron-Frederik Popov
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, London, U.K
| | - Anton Sabashnikov
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, London, U.K
| | - Nikhil P. Patil
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, London, U.K
| | - Mohamed Zeriouh
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, London, U.K
| | - Prashant N. Mohite
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, London, U.K
| | - Bartlomiej Zych
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, London, U.K
| | - Diana Garcia Saez
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, London, U.K
| | - Bastian Schmack
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Pascal M. Dohmen
- Department of Cardiovascular Surgery, Charite University Medicine, Berlin, Germany
- Department of Cardiothoracic Surgery, University of the Free State, Bloemfontein, South Africa
| | - Matthias Karck
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Andre R. Simon
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, London, U.K
| | - Alexander Weymann
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, London, U.K
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
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Motoyama H, Chen F, Hijiya K, Kondo T, Ohata K, Takahashi M, Yamada T, Sato M, Aoyama A, Date H. Novel thermographic detection of regional malperfusion caused by a thrombosis during ex vivo lung perfusion. Interact Cardiovasc Thorac Surg 2014; 20:242-7. [PMID: 25410766 DOI: 10.1093/icvts/ivu386] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Although ex vivo lung perfusion (EVLP) has been clinically applied as a novel rig to evaluate marginal donor lungs, no parameters have been reported to objectively detect regional lung damage during EVLP. The aim of this study was to investigate whether regional donor lung malperfusion-related damage caused by a thrombus could be detected by thermography during EVLP. METHODS Lewis rats were divided into two groups: the Thrombosis group and the Control group (n = 6 in each group). All rats were heparinized and the lungs were flushed with 20 ml of Steen solution. In the Thrombosis group, a 30-mg artificial thrombus was inserted into the left main pulmonary artery. All the lungs were perfused and ventilated using the EVLP system. Perfusion flow was increased every 2 min up to 10 ml/min. The lungs were evaluated by collecting thermographical and physiological data during EVLP. RESULTS Pulmonary artery pressure was higher and lung compliance was lower in the Thrombosis group compared with those in the Control group (P = 0.0005 and <0.0001, respectively). Macroscopically, no differences were seen between the perfused area and the malperfused area, whereas significant differences were detected between them by thermography. The surface temperature of both lungs in the Control group and the right lungs in the Thrombosis group rose with increasing perfusion flow, whereas the surface temperature of the left lungs in the Thrombosis group did not rise (P < 0.0001). CONCLUSIONS Although physiological data could possibly imply the existence of thrombi in the Thrombosis group, it could not reveal which area was obstructed by thrombi; however, thermography could detect a malperfused region. Thermographical evaluation may become a promising strategy to detect regional damage in donor lungs.
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Affiliation(s)
- Hideki Motoyama
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fengshi Chen
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kyoko Hijiya
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kondo
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Keiji Ohata
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mamoru Takahashi
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tetsu Yamada
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akihiro Aoyama
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Lung transplantation from donors after circulatory death using portable ex vivo lung perfusion. Can Respir J 2014; 22:47-51. [PMID: 25379654 DOI: 10.1155/2015/357498] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Donation after circulatory death is a novel method of increasing the number of donor lungs available for transplantation. Using organs from donors after circulatory death has the potential to increase the number of transplants performed. METHODS Three bilateral lung transplants from donors after circulatory death were performed over a six-month period. Following organ retrieval, all sets of lungs were placed on a portable ex vivo lung perfusion device for evaluation and preservation. RESULTS Lung function remained stable during portable ex vivo perfusion, with improvement in partial pressure of oxygen/fraction of inspired oxygen ratios. Mechanical ventilation was discontinued within 48 h for each recipient and no patient stayed in the intensive care unit longer than eight days. There was no postgraft dysfunction at 72 h in two of the three recipients. Ninety-day mortality for all recipients was 0% and all maintain excellent forced expiratory volume in 1 s and forced vital capacity values post-transplantation. CONCLUSION The authors report excellent results with their initial experience using donors after circulatory death after portable ex vivo lung perfusion. It is hoped this will allow for the most efficient use of available donor lungs, leading to more transplants and fewer deaths for potential recipients on wait lists.
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Whitson BA, Hertz MI, Kelly RF, Higgins RS, Kilic A, Shumway SJ, D’Cunha J. Use of the Donor Lung After Asphyxiation or Drowning: Effect on Lung Transplant Recipients. Ann Thorac Surg 2014; 98:1145-51. [DOI: 10.1016/j.athoracsur.2014.05.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/04/2014] [Accepted: 05/07/2014] [Indexed: 10/24/2022]
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Abstract
Lung transplantation (LTx) is an established treatment option for eligible patients with end-stage lung disease. Nevertheless, the imbalance between suitable donor lungs available and the increasing number of patients considered for LTx reflects in considerable waitlist mortality. Among potential alternatives to address this issue, ex vivo lung perfusion (EVLP) has emerged as a modern preservation technique that allows for more accurate lung assessment and also improvement of lung function. Its application in high-risk donor lungs has been successful and resulted in safe expansion of the donor pool. This article will: (I) review the technical details of EVLP; (II) the rationale behind the method; (III) report the worldwide clinical experience with the EVLP, including the Toronto technique and others; (IV) finally, discuss the growing literature on EVLP application for donation after cardiac death (DCD) lungs.
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Affiliation(s)
- Tiago N Machuca
- Toronto Lung Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada
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Motoyama H, Chen F, Hijiya K, Kondo T, Ohsumi A, Yamada T, Sato M, Aoyama A, Bando T, Date H. Plasmin administration during ex vivo lung perfusion ameliorates lung ischemia-reperfusion injury. J Heart Lung Transplant 2014; 33:1093-9. [PMID: 25043623 DOI: 10.1016/j.healun.2014.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 04/04/2014] [Accepted: 06/04/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Donor lung thrombus is considered a significant etiology for primary graft dysfunction (PGD). We hypothesized that thrombolysis in ex vivo lung perfusion (EVLP) before lung transplantation could alleviate ischemia-reperfusion injury (IRI), resulting in a decreased incidence of PGD. METHODS Rats were divided into control (n = 5), non-plasmin (n = 7) and plasmin (n = 7) groups. In the non-plasmin and plasmin groups, cardiac arrest was induced by withdrawal of ventilation without heparinization. After 120 minutes of warm ischemia, the lungs were ventilated and flushed. Hearts and both lungs were excised en bloc. The lungs were perfused and ventilated in the EVLP for 30 minutes, and plasmin or placebo was administered on EVLP initiation. The lungs were then stored at 4°C for 90 minutes and finally perfused with rat blood for 80 minutes. We assessed physiologic and histologic findings during reperfusion and the correlation between physiologic data during EVLP and after reperfusion. RESULTS Physiologic results were better in the plasmin group than in the non-plasmin group. The plasmin group lungs had fewer signs of histologic injury. Caspase-3 and -7 activity in the plasmin group was lower in the non-plasmin group. Pulmonary vascular resistance (PVR) during EVLP correlated with that at the end of reperfusion. CONCLUSIONS Plasmin administration during EVLP protected the donor lungs after reperfusion. We also found that several physiologic values in EVLP may be predictive markers of lung function after reperfusion.
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Affiliation(s)
- Hideki Motoyama
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fengshi Chen
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kyoko Hijiya
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kondo
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tetsu Yamada
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akihiro Aoyama
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toru Bando
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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Noda K, Shigemura N, Tanaka Y, Bhama JK, D'Cunha J, Luketich JD, Bermudez CA. Successful prolonged ex vivo lung perfusion for graft preservation in rats. Eur J Cardiothorac Surg 2014; 45:e54-60. [DOI: 10.1093/ejcts/ezt598] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Mariani AW, Medeiros IL, Pêgo-Fernandes PM, Fernandes FG, Unterpertinguer FDV, Fernandes LM, Cardoso PF, Canzian M, Jatene FB. Cold ischemia or topical-ECMO for lung preservation: a randomized experimental study. SAO PAULO MED J 2014; 132:28-35. [PMID: 24474077 PMCID: PMC10889451 DOI: 10.1590/1516-3180.2014.1321594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 05/15/2013] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Lung preservation remains a challenging issue for lung transplantation groups. Along with the development of ex vivo lung perfusion, a new preservation method known as topical-ECMO (extracorporal membrane oxygenation) has been proposed. The present study compared topical-ECMO with cold ischemia (CI) for lung preservation in an ex vivo experimental model. DESIGN AND SETTING Randomized experimental study, conducted at a public medical school. METHOD Fourteen human lungs were retrieved from seven brain-dead donors that were considered unsuitable for transplantation. The lung bloc was divided and each lung was randomized to be preserved by means of topical-ECMO or CI (4-7 °C) for eight hours. These lungs were then reconnected to an ex vivo perfusion system for functional evaluation. Lung biopsies were obtained at three times. The functional variables assessed were oxygenation capacity (OC) and pulmonary artery pressure (PAP); and the histological variables were lung injury score (LIS) and apoptotic cell count (ACC). RESULTS The mean OC was 468 mmHg (± 81.6) in the topical-ECMO group and 455.8 (± 54) for CI (P = 0.758). The median PAP was 140 mmHg (120-160) in the topical-ECMO group and 140 mmHg (140-150) for CI (P = 0.285). The mean LIS was 35.57 (± 4.5) in the topical-ECMO group and 33.86 (± 6.1) for CI (P = 0.367). The ACC was 25.00 (± 9.34) in the topical-ECMO group and 24.86 (± 10.374) for CI (P = 0.803). CONCLUSIONS The present study showed that topical-ECMO was not superior to cold ischemia for up to eight hours of lung preservation.
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Affiliation(s)
| | - Israel Lopes Medeiros
- Department of Thoracic Surgery, Hospital de Messejana, Fortaleza, Brazil, MD, PhD. Attending Physician, Department of Thoracic Surgery, Hospital de Messejana, Fortaleza, Brazil
| | - Paulo Manuel Pêgo-Fernandes
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil, MD, PhD. Full Professor of Thoracic Surgery, Instituto do Coração (InCor), Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Flavio Guimarães Fernandes
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil, Medical Student, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Fernando Do Vale Unterpertinguer
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil, Medical Student, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Lucas Matos Fernandes
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil, MD. Attending Physician, Department of Thoracic and Cardiovascular Surgery, Instituto do Coração (InCor), Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Paulo Francisco Cardoso
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil, MD, PhD. Professor, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Mauro Canzian
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil, MD, PhD. Attending Physician, Department of Pathology, Instituto do Coração (InCor), Hospital das Clínicas (HC), Faculdade de Medicina de Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Fabio Biscegli Jatene
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil, MD, PhD. Full Professor of Cardiovascular Surgery, Head of Thoracic and Cardiovascular Surgery Departament, Instituto do Coração (InCor), Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
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Abstract
After a brief review of conventional lung preservation, this article discusses the rationale behind ex vivo lung perfusion and how it has shifted the paradigm of organ preservation from conventional static cold ischemia to the utilization of functional normothermia, restoring the lung's own metabolism and its reparative processes. Technical aspects and previous clinical experience as well as opportunities to address specific donor organ injuries in a personalized medicine approach are also reviewed.
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Reconditioning lungs donated after cardiac death using short-term hypothermic machine perfusion. Transplantation 2013; 94:999-1004. [PMID: 23073465 DOI: 10.1097/tp.0b013e31826f632e] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Hypothermic machine perfusion (HMP) is widely used to preserve kidneys and livers for transplantation. This study investigated whether short-term HMP could improve the quality of lungs donated after cardiac death (DCD). METHODS In a clinically relevant uncontrolled DCD model, beagles were divided into two groups (n=5 each): 4 hr warm ischemia + 14 hr static cold storage (SCS group) or 4 hr warm ischemia + 12 hr SCS followed by 2 hr HMP (HMP group). HMP was performed using centrifugal perfusion with STEEN solution at approximately 10°C. In both groups, the left lungs were then transplanted and reperfused for 4 hr to evaluate the posttransplantation lung functions. RESULTS HMP was performed safely, not inducing any oxidative damage. The dynamic pulmonary compliance was stable during HMP, whereas the pulmonary vascular resistance significantly decreased. HMP microscopically eliminated residual microthrombi in the donor lungs just before transplantation. The lung tissue adenosine triphosphate levels 4 hr after reperfusion were significantly higher in the HMP group compared with the SCS group. The serum malondialdehyde levels and proinflammatory cytokine levels in the bronchoalveolar lavage fluid 4 hr after reperfusion were significantly lower in the HMP group than in the SCS group. The physiologic lung functions during reperfusion were significantly better in the HMP group compared with the SCS group. HMP also significantly reduced ischemia-reperfusion injury in the microscopic findings. CONCLUSIONS Short-term HMP could resuscitate ischemically damaged DCD lungs and ameliorate ischemia-reperfusion injury.
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Current world literature. Curr Opin Organ Transplant 2013; 18:241-50. [PMID: 23486386 DOI: 10.1097/mot.0b013e32835f5709] [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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Sereinigg M, Stiegler P, Puntschart A, Seifert-Held T, Zmugg G, Wiederstein-Grasser I, Marte W, Marko T, Bradatsch A, Tscheliessnigg K, Stadlbauer-Köllner V. Establishing a brain-death donor model in pigs. Transplant Proc 2013; 44:2193-6. [PMID: 22974951 DOI: 10.1016/j.transproceed.2012.07.104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION An animal model that imitates human conditions might be useful not only to monitor pathomechanisms of brain death and biochemical cascades but also to investigate novel strategies to ameliorate organ quality and functionality after multiorgan donation. METHODS Brain death was induced in 15 pigs by inserting a catheter into the intracranial space after trephination of the skull and augmenting intracranial pressure until brain stem herniation. Intracranial pressure was monitored continuously; after 60 minutes, brain death diagnostics were performed by a neurologist including electroencephalogram (EEG) and clinical examinations. Clinical examinations included testing of brain stem reflexes as well as apnoe testing; then intensive donor care was performed according to standard guidelines until 24 hours after confirmation of brain death. Intensive donor care was performed according to standard guidelines for 24 hours after brain death. RESULTS Sixty minutes after brain-death induction, neurological examination and EEG examination confirmed brain death. Intracranial pressure increased continuously, remaining stable after the occurrence of brain death. All 15 animals showed typical signs of brain death such as diabetes insipidus, hypertensive and hypotensive periods, as well as tachycardia. All symptoms were treated with standard medications. After 24 hours of brain death we performed successful multiorgan retrieval. DISCUSSION Brain death can be induced in a pig model by inserting a catheter after trephination of the skull. According to standard guidelines the brain-death diagnosis was established by a flat-line EEG, which occurred in all animals at 60 minutes after induction.
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Affiliation(s)
- M Sereinigg
- Department of Transplantation Surgery, Medical University Graz, Graz, Austria
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