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Iskender I. Technical Advances Targeting Multiday Preservation of Isolated Ex Vivo Lung Perfusion. Transplantation 2024; 108:1319-1332. [PMID: 38499501 DOI: 10.1097/tp.0000000000004992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Indications for ex vivo lung perfusion (EVLP) have evolved from assessment of questionable donor lungs to treatment of some pathologies and the logistics. Yet up to 3 quarters of donor lungs remain discarded across the globe. Multiday preservation of discarded human lungs on EVLP platforms would improve donor lung utilization rates via application of sophisticated treatment modalities, which could eventually result in zero waitlist mortality. The purpose of this article is to summarize advances made on the technical aspects of the protocols in achieving a stable multiday preservation of isolated EVLP. Based on the evidence derived from large animal and/or human studies, the following advances have been considered important in achieving this goal: ability to reposition donor lungs during EVLP; perfusate adsorption/filtration modalities; perfusate enrichment with plasma and/or donor whole blood, nutrients, vitamins, and amino acids; low-flow, pulsatile, and subnormothermic perfusion; positive outflow pressure; injury specific personalized ventilation strategies; and negative pressure ventilation. Combination of some of these advances in an automatized EVLP device capable of managing perfusate biochemistry and ventilation would likely speed up the processes of achieving multiday preservation of isolated EVLP.
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Affiliation(s)
- Ilker Iskender
- Department of Cardiac Surgery, East Limburg Hospital, Genk, Belgium
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Ricardo-da-Silva FY, Armstrong-Jr R, Ramos MMDA, Vidal-Dos-Santos M, Jesus Correia C, Ottens PJ, Moreira LFP, Leuvenink HGD, Breithaupt-Faloppa AC. Male versus female inflammatory response after brain death model followed by ex vivo lung perfusion. Biol Sex Differ 2024; 15:11. [PMID: 38287395 PMCID: PMC10826050 DOI: 10.1186/s13293-024-00581-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 01/02/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is a useful tool for assessing lung grafts quality before transplantation. Studies indicate that donor sex is as an important factor for transplant outcome, as females present higher inflammatory response to brain death (BD) than males. Here, we investigated sex differences in the lungs of rats subjected to BD followed by EVLP. METHODS Male and female Wistar rats were subjected to BD, and as controls sham animals. Arterial blood was sampled for gas analysis. Heart-lung blocks were kept in cold storage (1 h) and normothermic EVLP carried out (4 h), meanwhile ventilation parameters were recorded. Perfusate was sampled for gas analysis and IL-1β levels. Leukocyte infiltration, myeloperoxidase presence, IL-1β gene expression, and long-term release in lung culture (explant) were evaluated. RESULTS Brain dead females presented a low lung function after BD, compared to BD-males; however, at the end of the EVLP period oxygenation capacity decreased in all BD groups. Overall, ventilation parameters were maintained in all groups. After EVLP lung infiltrate was higher in brain dead females, with higher neutrophil content, and accompanied by high IL-1β levels, with increased gene expression and concentration in the culture medium (explant) 24 h after EVLP. Female rats presented higher lung inflammation after BD than male rats. Despite maintaining lung function and ventilation mechanics parameters for 4 h, EVLP was not able to alter this profile. CONCLUSION In this context, further studies should focus on therapeutic measures to control inflammation in donor or during EVLP to increase lung quality.
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Affiliation(s)
- Fernanda Yamamoto Ricardo-da-Silva
- Laboratorio de Cirurgia Cardiovascular e Fisiopatologia da Circulação (LIM-11), HC-FMUSP, Instituto Do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 2º Andar, Sala 2146, São Paulo, 01246-903, Brazil
| | - Roberto Armstrong-Jr
- Laboratorio de Cirurgia Cardiovascular e Fisiopatologia da Circulação (LIM-11), HC-FMUSP, Instituto Do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 2º Andar, Sala 2146, São Paulo, 01246-903, Brazil
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Mayara Munhoz de Assis Ramos
- Laboratorio de Cirurgia Cardiovascular e Fisiopatologia da Circulação (LIM-11), HC-FMUSP, Instituto Do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 2º Andar, Sala 2146, São Paulo, 01246-903, Brazil
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Marina Vidal-Dos-Santos
- Laboratorio de Cirurgia Cardiovascular e Fisiopatologia da Circulação (LIM-11), HC-FMUSP, Instituto Do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 2º Andar, Sala 2146, São Paulo, 01246-903, Brazil
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Cristiano Jesus Correia
- Laboratorio de Cirurgia Cardiovascular e Fisiopatologia da Circulação (LIM-11), HC-FMUSP, Instituto Do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 2º Andar, Sala 2146, São Paulo, 01246-903, Brazil
| | - Petra J Ottens
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Luiz Felipe Pinho Moreira
- Laboratorio de Cirurgia Cardiovascular e Fisiopatologia da Circulação (LIM-11), HC-FMUSP, Instituto Do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 2º Andar, Sala 2146, São Paulo, 01246-903, Brazil
| | - Henri G D Leuvenink
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Ana Cristina Breithaupt-Faloppa
- Laboratorio de Cirurgia Cardiovascular e Fisiopatologia da Circulação (LIM-11), HC-FMUSP, Instituto Do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455 2º Andar, Sala 2146, São Paulo, 01246-903, Brazil.
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Ling Z, Noda K, Frey BL, Hu M, Fok SW, Smith LM, Sanchez PG, Ren X. Newly synthesized glycoprotein profiling to identify molecular signatures of warm ischemic injury in donor lungs. Am J Physiol Lung Cell Mol Physiol 2023; 325:L30-L44. [PMID: 37130807 PMCID: PMC10292982 DOI: 10.1152/ajplung.00412.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/24/2023] [Accepted: 04/29/2023] [Indexed: 05/04/2023] Open
Abstract
Despite recent technological advances such as ex vivo lung perfusion (EVLP), the outcome of lung transplantation remains unsatisfactory with ischemic injury being a common cause for primary graft dysfunction. New therapeutic developments are hampered by limited understanding of pathogenic mediators of ischemic injury to donor lung grafts. Here, to identify novel proteomic effectors underlying the development of lung graft dysfunction, using bioorthogonal protein engineering, we selectively captured and identified newly synthesized glycoproteins (NewS-glycoproteins) produced during EVLP with unprecedented temporal resolution of 4 h. Comparing the NewS-glycoproteomes in lungs with and without warm ischemic injury, we discovered highly specific proteomic signatures with altered synthesis in ischemic lungs, which exhibited close association to hypoxia response pathways. Inspired by the discovered protein signatures, pharmacological modulation of the calcineurin pathway during EVLP of ischemic lungs offered graft protection and improved posttransplantation outcome. In summary, the described EVLP-NewS-glycoproteomics strategy delivers an effective new means to reveal molecular mediators of donor lung pathophysiology and offers the potential to guide future therapeutic development.NEW & NOTEWORTHY This study developed and implemented a bioorthogonal strategy to chemoselectively label, enrich, and characterize newly synthesized (NewS-)glycoproteins during 4-h ex vivo lung perfusion (EVLP). Through this approach, the investigators uncovered specific proteomic signatures associated with warm ischemic injury in donor lung grafts. These signatures exhibit high biological relevance to ischemia-reperfusion injury, validating the robustness of the presented approach.
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Affiliation(s)
- Zihan Ling
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States
| | - Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Brian L Frey
- Department of Chemistry, University of Wisconsin, Madison, Wisconsin, United States
| | - Michael Hu
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States
| | - Shierly W Fok
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States
| | - Lloyd M Smith
- Department of Chemistry, University of Wisconsin, Madison, Wisconsin, United States
| | - Pablo G Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Xi Ren
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States
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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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Hatami S, Hefler J, Freed DH. Inflammation and Oxidative Stress in the Context of Extracorporeal Cardiac and Pulmonary Support. Front Immunol 2022; 13:831930. [PMID: 35309362 PMCID: PMC8931031 DOI: 10.3389/fimmu.2022.831930] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal circulation (ECC) systems, including cardiopulmonary bypass, and extracorporeal membrane oxygenation have been an irreplaceable part of the cardiothoracic surgeries, and treatment of critically ill patients with respiratory and/or cardiac failure for more than half a century. During the recent decades, the concept of extracorporeal circulation has been extended to isolated machine perfusion of the donor organ including thoracic organs (ex-situ organ perfusion, ESOP) as a method for dynamic, semi-physiologic preservation, and potential improvement of the donor organs. The extracorporeal life support systems (ECLS) have been lifesaving and facilitating complex cardiothoracic surgeries, and the ESOP technology has the potential to increase the number of the transplantable donor organs, and to improve the outcomes of transplantation. However, these artificial circulation systems in general have been associated with activation of the inflammatory and oxidative stress responses in patients and/or in the exposed tissues and organs. The activation of these responses can negatively affect patient outcomes in ECLS, and may as well jeopardize the reliability of the organ viability assessment, and the outcomes of thoracic organ preservation and transplantation in ESOP. Both ECLS and ESOP consist of artificial circuit materials and components, which play a key role in the induction of these responses. However, while ECLS can lead to systemic inflammatory and oxidative stress responses negatively affecting various organs/systems of the body, in ESOP, the absence of the organs that play an important role in oxidant scavenging/antioxidative replenishment of the body, such as liver, may make the perfused organ more susceptible to inflammation and oxidative stress during extracorporeal circulation. In the present manuscript, we will review the activation of the inflammatory and oxidative stress responses during ECLP and ESOP, mechanisms involved, clinical implications, and the interventions for attenuating these responses in ECC.
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Affiliation(s)
- Sanaz Hatami
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
| | - Joshua Hefler
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H. Freed
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Department of Physiology, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Darren H. Freed,
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Selo MA, Sake JA, Kim KJ, Ehrhardt C. In vitro and ex vivo models in inhalation biopharmaceutical research - advances, challenges and future perspectives. Adv Drug Deliv Rev 2021; 177:113862. [PMID: 34256080 DOI: 10.1016/j.addr.2021.113862] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022]
Abstract
Oral inhalation results in pulmonary drug targeting and thereby reduces systemic side effects, making it the preferred means of drug delivery for the treatment of respiratory disorders such as asthma, chronic obstructive pulmonary disease or cystic fibrosis. In addition, the high alveolar surface area, relatively low enzymatic activity and rich blood supply of the distal airspaces offer a promising pathway to the systemic circulation. This is particularly advantageous when a rapid onset of pharmacological action is desired or when the drug is suffering from stability issues or poor biopharmaceutical performance following oral administration. Several cell and tissue-based in vitro and ex vivo models have been developed over the years, with the intention to realistically mimic pulmonary biological barriers. It is the aim of this review to critically discuss the available models regarding their advantages and limitations and to elaborate further which biopharmaceutical questions can and cannot be answered using the existing models.
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Miyamoto E, Takahagi A, Ohsumi A, Martinu T, Hwang D, Boonstra KM, Joe B, Umana JM, Bei KF, Vosoughi D, Liu M, Cypel M, Keshavjee S, Juvet SC. Ex vivo delivery of regulatory T cells for control of alloimmune priming in the donor lung. Eur Respir J 2021; 59:13993003.00798-2021. [PMID: 34475226 DOI: 10.1183/13993003.00798-2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/17/2021] [Indexed: 11/05/2022]
Abstract
Survival after lung transplantation (LTx) is hampered by uncontrolled inflammation and alloimmunity. Regulatory T cells (Tregs) are being studied as a cellular therapy in solid organ transplantation. Whether these systemically administered Tregs can function at the appropriate location and time is an important concern. We hypothesized that in vitro expanded, recipient-derived Tregs can be delivered to donor lungs prior to LTx via ex vivo lung perfusion (EVLP), maintaining their immunomodulatory ability.In a rat model, Wistar Kyoto (WKy) CD4+CD25high Tregs were expanded in vitro prior to EVLP. Expanded Tregs were administered to Fisher 344 (F344) donor lungs during EVLP; left lungs were transplanted into WKy recipients. Treg localisation and function post-transplant were assessed. In a proof-of-concept experiment, cryopreserved expanded human CD4+CD25+CD127low Tregs were thawed and injected into discarded human lungs during EVLP.Rat Tregs entered the lung parenchyma and retained suppressive function. Expanded Tregs had no adverse effect on donor lung physiology during EVLP; lung water as measured by wet-to-dry weight ratio was reduced by Treg therapy. The administered cells remained in the graft at 3 days post-transplant where they reduced activation of intragraft effector CD4+ T cells; these effects were diminished by day 7. Human Tregs entered the lung parenchyma during EVLP where they expressed key immunoregulatory molecules (CTLA4+, 4-1BB+, CD39+, and CD15s+).Pre-transplant Treg administration can inhibit alloimmunity within the lung allograft at early time points post- transplant. Our organ-directed approach has potential for clinical translation.
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Affiliation(s)
- Ei Miyamoto
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Akihiro Takahagi
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Akihiro Ohsumi
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David Hwang
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kristen M Boonstra
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Betty Joe
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Juan Mauricio Umana
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ke F Bei
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Vosoughi
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stephen C Juvet
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Cyclosporin A Administration During Ex Vivo Lung Perfusion Preserves Lung Grafts in Rat Transplant Model. Transplantation 2020; 104:e252-e259. [PMID: 32217944 DOI: 10.1097/tp.0000000000003237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Despite the benefits of ex vivo lung perfusion (EVLP) such as lung reconditioning, preservation, and evaluation before transplantation, deleterious effects, including activation of proinflammatory cascades and alteration of metabolic profiles have been reported. Although patient outcomes have been favorable, further studies addressing optimal conditions are warranted. In this study, we investigated the role of the immunosuppressant drug cyclosporine A (CyA) in preserving mitochondrial function and subsequently preventing proinflammatory changes in lung grafts during EVLP. METHODS Using rat heart-lung blocks after 1-hour cold preservation, an acellular normothermic EVLP system was established for 4 hours. CyA was added into perfusate at a final concentration of 1 μM. The evaluation included lung graft function, lung compliance, and pulmonary vascular resistance as well as biochemical marker measurement in the perfusate at multiple time points. After EVLP, single orthotopic lung transplantation was performed, and the grafts were assessed 2 hours after reperfusion. RESULTS Lung grafts on EVLP with CyA exhibited significantly better functional and physiological parameters as compared with those without CyA treatment. CyA administration attenuated proinflammatory changes and prohibited glucose consumption during EVLP through mitigating mitochondrial dysfunction in lung grafts. CyA-preconditioned lungs showed better posttransplant lung early graft function and less inflammatory events compared with control. CONCLUSIONS During EVLP, CyA administration can have a preconditioning effect through both its anti-inflammatory and mitochondrial protective properties, leading to improved lung graft preservation, which may result in enhanced graft quality after transplantation.
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Wang A, Ali A, Keshavjee S, Liu M, Cypel M. Ex vivo lung perfusion for donor lung assessment and repair: a review of translational interspecies models. Am J Physiol Lung Cell Mol Physiol 2020; 319:L932-L940. [PMID: 32996780 DOI: 10.1152/ajplung.00295.2020] [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] [Indexed: 12/13/2022] Open
Abstract
For patients with end-stage lung disease, lung transplantation is a lifesaving therapy. Currently however, the number of patients who require a transplant exceeds the number of donor lungs available. One of the contributing factors to this is the conservative mindset of physicians who are concerned about transplanting marginal lungs due to the potential risk of primary graft dysfunction. Ex vivo lung perfusion (EVLP) technology has allowed for the expansion of donor pool of organs by enabling assessment and reconditioning of these marginal grafts before transplant. Ongoing efforts to optimize the therapeutic potential of EVLP are underway. Researchers have adopted the use of different large and small animal models to generate translational preclinical data. This includes the use of rejected human lungs, pig lungs, and rat lungs. In this review, we summarize some of the key current literature studies relevant to each of the major EVLP model platforms and identify the advantages and disadvantages of each platform. The review aims to guide investigators in choosing an appropriate species model to suit their specific goals of study, and ultimately aid in translation of therapy to meet the growing needs of the patient population.
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Affiliation(s)
- Aizhou Wang
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aadil Ali
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Jin Z, Hana Z, Alam A, Rajalingam S, Abayalingam M, Wang Z, Ma D. Review 1: Lung transplant-from donor selection to graft preparation. J Anesth 2020; 34:561-574. [PMID: 32476043 PMCID: PMC7261511 DOI: 10.1007/s00540-020-02800-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 05/17/2020] [Indexed: 12/16/2022]
Abstract
For various end-stage lung diseases, lung transplantation remains one of the only viable treatment options. While the demand for lung transplantation has steadily risen over the last few decades, the availability of donor grafts is limited, which have resulted in progressively longer waiting lists. In the early years of lung transplantation, only the 'ideal' donor grafts are considered for transplantation. Due to the donor shortages, there is ongoing discussion about the safe use of 'suboptimal' grafts to expand the donor pool. In this review, we will discuss the considerations around donor selection, donor-recipient matching, graft preparation and graft optimisation.
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Affiliation(s)
- Zhaosheng Jin
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK
| | - Zac Hana
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK
| | - Azeem Alam
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK
| | - Shamala Rajalingam
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK
| | - Mayavan Abayalingam
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK
| | - Zhiping Wang
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Daqing Ma
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK.
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Iskender I, Arni S, Maeyashiki T, Citak N, Sauer M, Rodriguez JM, Frauenfelder T, Opitz I, Weder W, Inci I. Perfusate adsorption during ex vivo lung perfusion improves early post-transplant lung function. J Thorac Cardiovasc Surg 2020; 161:e109-e121. [PMID: 32201002 DOI: 10.1016/j.jtcvs.2019.12.128] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 11/29/2019] [Accepted: 12/05/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Improvement in ex vivo lung perfusion protocols could increase the number of donors available for transplantation and protect the lungs from primary graft dysfunction. We hypothesize that perfusate adsorption during ex vivo lung perfusion reconditions the allograft to ischemia-reperfusion injury after lung transplantation. METHODS Donor pig lungs were preserved for 24 hours at 4°C, followed by 6 hours of ex vivo lung perfusion according to the Toronto protocol. The perfusate was additionally adsorbed through a CytoSorb adsorber (CytoSorbents, Berlin, Germany) in the treatment group, whereas control lungs were perfused according to the standard protocol (n = 5, each). Ex vivo lung perfusion physiology and biochemistry were monitored. Upon completion of ex vivo lung perfusion, a left single lung transplantation was performed. Oxygenation function and lung mechanics were assessed during a 4-hour reperfusion period. The inflammatory response was determined during ex vivo lung perfusion and reperfusion. RESULTS The cytokine concentrations in the perfusate were markedly lower with the adsorber, resulting in improved ex vivo lung perfusion physiology and biochemistry during the 6-hour perfusion period. Post-transplant dynamic lung compliance was markedly better during the 4-hour reperfusion period in the treatment group. Isolated allograft oxygenation function and dynamic compliance continued to be superior in the adsorber group at the end of reperfusion, accompanied by a markedly decreased local inflammatory response. CONCLUSIONS Implementation of an additional cytokine adsorber has refined the standard ex vivo lung perfusion protocol. Furthermore, cytokine removal during ex vivo lung perfusion improved immediate post-transplant graft function together with a less intense inflammatory response to reperfusion in pigs. Further studies are warranted to understand the beneficial effects of perfusate adsorption during ex vivo lung perfusion in the clinical setting.
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Affiliation(s)
- Ilker Iskender
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Stephan Arni
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Tatsuo Maeyashiki
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Necati Citak
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Mareike Sauer
- Department of Surgical Research, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | | | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland.
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12
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Burki S, Noda K, Philips BJ, Velayutham M, Shiva S, Sanchez PG, Kumar A, D'Cunha J. Impact of triptolide during ex vivo lung perfusion on grafts after transplantation in a rat model. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)30191-4. [PMID: 32169373 DOI: 10.1016/j.jtcvs.2019.12.104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/30/2019] [Accepted: 12/19/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Ex vivo lung perfusion creates a proinflammatory environment leading to deterioration in graft quality that may contribute to post-transplant graft dysfunction. Triptolide has been shown to have a therapeutic potential in various disease states because of its anti-inflammatory properties. On this basis, we investigated the impact of triptolide on graft preservation during ex vivo lung perfusion and associated post-transplant outcomes in a rat transplant model. METHODS We performed rat normothermic ex vivo lung perfusion with acellular Steen solution containing 100 nM triptolide for 4 hours and compared the data with untreated lungs. Orthotopic single lung transplantation after ex vivo lung perfusion was performed. RESULTS Physiologic and functional parameters of lung grafts on ex vivo lung perfusion with triptolide were better than those without treatment. Graft glucose consumption was significantly attenuated on ex vivo lung perfusion with triptolide via inhibition of hypoxia signaling resulting in improved mitochondrial function and reduced oxidative stress. Also, intragraft inflammation was markedly lower in triptolide-treated lungs because of inhibition of nuclear factor-κB signaling. Furthermore, post-transplant graft function and inflammatory events were significantly improved in the triptolide group compared with the untreated group. CONCLUSIONS Treatment of lung grafts with triptolide during ex vivo lung perfusion may serve to enhance graft preservation and improve graft protection resulting in better post-transplant outcomes.
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Affiliation(s)
- Sarah Burki
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Brian J Philips
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Murugesan Velayutham
- Department of Medicine, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pa; Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Sruti Shiva
- Department of Medicine, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Pablo G Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Ajay Kumar
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Pheonix, Ariz.
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13
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Okamoto T, Niikawa H, Ayyat K, Sakanoue I, Said S, McCurry KR. Machine Perfusion of Lungs. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00258-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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14
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15
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Optimization of oxygenation during ex vivo lung perfusion—Best basic science article in 2017. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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16
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Boisen ML, Sardesai MP, Kolarczyk L, Rao VK, Owsiak CP, Gelzinis TA. The Year in Thoracic Anesthesia: Selected Highlights From 2017. J Cardiothorac Vasc Anesth 2018; 32:1556-1569. [PMID: 29655515 DOI: 10.1053/j.jvca.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Michael L Boisen
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - Mahesh P Sardesai
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
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17
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Abstract
This article summarizes recent knowledge and clinical advances in machine perfusion (MP) of thoracic organs. MP of thoracic organs has gained much attention during the last decade. Clinical studies are investigating the role of MP to preserve, resuscitate, and assess heart and lungs prior to transplantation. Currently, MP of the cardiac allograft is essential in all type DCD heart transplantation while MP of the pulmonary allograft is mandatory in uncontrolled DCD lung transplantation. MP of thoracic organs also offers an exciting platform to further investigate downregulation of the innate and adaptive immunity prior to reperfusion of the allograft in recipients. MP provides a promising technology that allows pre-transplant preservation, resuscitation, assessment, repair, and conditioning of cardiac and pulmonary allografts outside the body in a near physiologic state prior to planned transplantation. Results of ongoing clinical trials are awaited to estimate the true clinical value of this new technology in advancing the field of heart and lung transplantation by increasing the total number and the quality of available organs and by further improving recipient early and long-term outcome.
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Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, KU Leuven University, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
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18
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Gelzinis TA. Anesthetic Management of Lung Transplantation: Center Specific Practices and Geographical and Centers Size Differences. J Cardiothorac Vasc Anesth 2018; 32:70-72. [DOI: 10.1053/j.jvca.2017.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Indexed: 12/26/2022]
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19
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Himmat S, Alzamil A, Aboelnazar N, Hatami S, White C, Dromparis P, Mengel M, Freed D, Nagendran J. A Decrease in Hypoxic Pulmonary Vasoconstriction Correlates With Increased Inflammation During Extended Normothermic Ex Vivo Lung Perfusion. Artif Organs 2017; 42:271-279. [PMID: 29266272 DOI: 10.1111/aor.13017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/12/2017] [Accepted: 08/04/2017] [Indexed: 02/06/2023]
Abstract
Normothermic ex vivo lung perfusion (EVLP) is an evolving technology to evaluate function of donor lungs to determine suitability for transplantation. We hypothesize that hypoxic pulmonary vasoconstriction (HPV) during EVLP will provide a more sensitive parameter of lung function to determine donor lung quality for lung transplantation. Eight porcine lungs were procured, and subsequently underwent EVLP with autologous blood and STEEN solution for 10 h. Standard physiologic parameters including dynamic compliance, peak airway pressure, and pulmonary vascular resistance (PVR) remained stable (P = 0.055), mean oxygenation (PO2 /FiO2 ) was 400 ± 18 mm Hg on average throughout perfusion. Response to hypoxia resulted in a robust increase in PVR (ΔPVR) up to 4 h of perfusion, however the HPV response then blunted beyond T6 (P < 0.01). The decrease in HPV response inversely correlated to cytokine concentrations of Interleukin-6 and tumor necrosis factor-α (P < 0.01). Despite acceptable lung oxygenation and standard physiologic parameters during 10 h of EVLP, there is a subclinical deterioration of lung function. HPV challenges can be performed during EVLP as a simple and more sensitive index of pulmonary vascular reactivity.
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Affiliation(s)
- Sayed Himmat
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Almothana Alzamil
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Nader Aboelnazar
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Sanaz Hatami
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Christopher White
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Peter Dromparis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Darren Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.,Division of Cardiac Surgery, Department of Surgery, Alberta Transplant Institute, Edmonton, Alberta, Canada.,Canadian National Transplant Research Program, Canadian Institute for Health Research, Edmonton, Alberta, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.,Division of Cardiac Surgery, Department of Surgery, Alberta Transplant Institute, Edmonton, Alberta, Canada.,Canadian National Transplant Research Program, Canadian Institute for Health Research, Edmonton, Alberta, Canada
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20
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Targeting Circulating Leukocytes and Pyroptosis During Ex Vivo Lung Perfusion Improves Lung Preservation. Transplantation 2017; 101:2841-2849. [PMID: 28452921 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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21
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Tane S, Noda K, Shigemura N. Ex Vivo Lung Perfusion. Chest 2017; 151:1220-1228. [DOI: 10.1016/j.chest.2017.02.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 02/10/2017] [Accepted: 02/15/2017] [Indexed: 02/04/2023] Open
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