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M M, Attawar S, BN M, Tisekar O, Mohandas A. Ex vivo lung perfusion and the Organ Care System: a review. CLINICAL TRANSPLANTATION AND RESEARCH 2024; 38:23-36. [PMID: 38725180 PMCID: PMC11075812 DOI: 10.4285/ctr.23.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/29/2024] [Accepted: 03/08/2024] [Indexed: 05/14/2024]
Abstract
With the increasing prevalence of heart failure and end-stage lung disease, there is a sustained interest in expanding the donor pool to alleviate the thoracic organ shortage crisis. Efforts to extend the standard donor criteria and to include donation after circulatory death have been made to increase the availability of suitable organs. Studies have demonstrated that outcomes with extended-criteria donors are comparable to those with standard-criteria donors. Another promising approach to augment the donor pool is the improvement of organ preservation techniques. Both ex vivo lung perfusion (EVLP) for the lungs and the Organ Care System (OCS, TransMedics) for the heart have shown encouraging results in preserving organs and extending ischemia time through the application of normothermic regional perfusion. EVLP has been effective in improving marginal or borderline lungs by preserving and reconditioning them. The use of OCS is associated with excellent short-term outcomes for cardiac allografts and has improved utilization rates of hearts from extended-criteria donors. While both EVLP and OCS have successfully transitioned from research to clinical practice, the costs associated with commercially available systems and consumables must be considered. The ex vivo perfusion platform, which includes both EVLP and OCS, holds the potential for diverse and innovative therapies, thereby transforming the landscape of thoracic organ transplantation.
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Affiliation(s)
- Menander M
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Sandeep Attawar
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Mahesh BN
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Owais Tisekar
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Anoop Mohandas
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
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2
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Ponholzer F, Dumfarth J, Krapf C, Pircher A, Hautz T, Wolf D, Augustin F, Schneeberger S. The impact and relevance of techniques and fluids on lung injury in machine perfusion of lungs. Front Immunol 2024; 15:1358153. [PMID: 38510260 PMCID: PMC10950925 DOI: 10.3389/fimmu.2024.1358153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
Primary graft dysfunction (PGD) is a common complication after lung transplantation. A plethora of contributing factors are known and assessment of donor lung function prior to organ retrieval is mandatory for determination of lung quality. Specialized centers increasingly perform ex vivo lung perfusion (EVLP) to further assess lung functionality and improve and extend lung preservation with the aim to increase lung utilization. EVLP can be performed following different protocols. The impact of the individual EVLP parameters on PGD development, organ function and postoperative outcome remains to be fully investigated. The variables relate to the engineering and function of the respective perfusion devices, such as the type of pump used, functional, like ventilation modes or physiological (e.g. perfusion solutions). This review reflects on the individual technical and fluid components relevant to EVLP and their respective impact on inflammatory response and outcome. We discuss key components of EVLP protocols and options for further improvement of EVLP in regard to PGD. This review offers an overview of available options for centers establishing an EVLP program and for researchers looking for ways to adapt existing protocols.
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Affiliation(s)
- Florian Ponholzer
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Julia Dumfarth
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Krapf
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Pircher
- Department of Haematology and Oncology, Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Theresa Hautz
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Dominik Wolf
- Department of Haematology and Oncology, Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Augustin
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
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3
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Beyersdorf F. Innovation and disruptive science determine the future of cardiothoracic surgery. Eur J Cardiothorac Surg 2024; 65:ezae022. [PMID: 38243711 DOI: 10.1093/ejcts/ezae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/12/2024] [Indexed: 01/21/2024] Open
Abstract
One of the currently most asked questions in the field of medicine is how any specialty in the future will evolve to ensure better health for the patients by using current, unparalleled developments in all areas of science. This article will give an overview of new and evolving strategies for cardiothoracic (CT) surgery that are available today and will become available in the future in order to achieve this goal. In the founding era of CT surgery in the 1950s and 1960s, there was tremendous excitement about innovation and disruptive science, which eventually resulted in a completely new medical specialty, i.e. CT surgery. Entirely new treatment strategies were introduced for many cardiovascular diseases that had been considered incurable until then. As expected, alternative techniques have evolved in all fields of science during the last few decades, allowing great improvements in diagnostics and treatment in all medical specialties. The future of CT surgery will be determined by an unrestricted and unconditional investment in innovation, disruptive science and our own transformation using current achievements from many other fields. From the multitude of current and future possibilities, I will highlight 4 in this review: improvements in our current techniques, bringing CT surgery to low- and middle-income countries, revolutionizing the perioperative period and treating as yet untreatable diseases. These developments will allow us a continuation of the previously unheard-of treatment possibilities provided by ingenious innovations based on the fundamentals of CT surgery.
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Affiliation(s)
- Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Freiburg, Germany
- Medical Faculty of the Albert-Ludwigs-University Freiburg, Germany
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4
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Zhou AL, Larson EL, Ruck JM, Ha JS, Casillan AJ, Bush EL. Current status and future potential of ex vivo lung perfusion in clinical lung transplantation. Artif Organs 2023; 47:1700-1709. [PMID: 37455548 DOI: 10.1111/aor.14607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/29/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023]
Abstract
Lung transplantation is accepted as a well-established and effective treatment for patients with end-stage lung disease. While the number of candidates added to the waitlist continues to rise, the number of transplants performed remains limited by the number of suitable organ donors. Ex vivo lung perfusion (EVLP) emerged as a method of addressing the organ shortage by allowing the evaluation and potential reconditioning of marginal donor lungs or minimizing risks of prolonged ischemic time due to logistical challenges. The currently available FDA-approved EVLP systems have demonstrated excellent outcomes in clinical trials, and retrospective studies have demonstrated similar post-transplant survival between recipients who received marginal donor lungs perfused using EVLP and recipients who received standard criteria lungs stored using conventional methods. Despite this, widespread utilization has plateaued in the last few years, likely due to the significant costs associated with initiating EVLP programs. Centralized, dedicated EVLP perfusion centers are currently being investigated as a potential method of further expanding utilization of this technology. In the preclinical setting, potential applications of EVLP that are currently being studied include prolongation of organ preservation, reconditioning of unsuitable lungs, and further enhancement of already suitable lungs. As adoption of EVLP technology becomes more widespread, we may begin to see future implementation of these potential applications into the clinical setting.
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Affiliation(s)
- Alice L Zhou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Emily L Larson
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jessica M Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jinny S Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alfred J Casillan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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5
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Wang Y, Tang M, Deng H, Hong Z, Liang Z, Huang Y, Zeng C, Yang K. Ampelopsin attenuates Staphylococcus aureus Alpha-Toxin-Induced Lung Injury. Microb Pathog 2023; 183:106316. [PMID: 37634577 DOI: 10.1016/j.micpath.2023.106316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 08/29/2023]
Abstract
Staphylococcus aureus is a prevalent cause of lung infections in hospitals and communities, and can cause a wide spectrum of human infections. Due to the bottleneck caused by antibiotic resistance and substantial increases in morbidity and mortality, targeting the virulence factors released by S. aureus as an alternative prevention and treatment method has become a promising approach. Ampelopsin, a component of vine tea, has promising potential for treating S. aureus-induced acute lung injury. In this study, the effects of ampelopsin were investigated on a mouse model of acute lung injury established using S. aureus 8325-4 and the α-hemolysin (hla) silent strain DU1090. The hla silent strain did not cause mortality in mice, whereas lethal and sublethal concentrations of S. aureus 8325-4 caused high mortality. Notably, ampelopsin treatment protected against mortality stemming from S. aureus infection. Ampelopsin yielded enhancements in lung barrier function, decreased total protein leakage in the alveolar lavage fluid, and modulated inflammatory signaling pathway-related proteins, thereby reducing the release of pro-inflammatory factors and improving respiratory dysfunction. Moreover, ampelopsin prevented the upregulation of ADAM10 activity, leading to E-cadherin mucin cleavage. In conclusion, our findings establish the key role of alpha -toxin in infectious lung injury in S. aureus and provide support for ampelopsin as an effective therapeutic approach to improve lung injury.
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Affiliation(s)
- Yi Wang
- School of Pharmacy, Guangxi University of Chinese Medicine, Nanning, 530200, PR China
| | - Mulan Tang
- School of Pharmacy, Guangxi University of Chinese Medicine, Nanning, 530200, PR China
| | - Haojian Deng
- School of Pharmacy, Guangxi University of Chinese Medicine, Nanning, 530200, PR China
| | - Zhengshan Hong
- School of Pharmacy, Guangxi University of Chinese Medicine, Nanning, 530200, PR China
| | - Zhi Liang
- School of Pharmacy, Guangxi University of Chinese Medicine, Nanning, 530200, PR China
| | - Yumei Huang
- School of Pharmacy, Guangxi University of Chinese Medicine, Nanning, 530200, PR China
| | - Chunhui Zeng
- School of Pharmacy, Guangxi University of Chinese Medicine, Nanning, 530200, PR China.
| | - Ke Yang
- School of Pharmacy, Guangxi University of Chinese Medicine, Nanning, 530200, PR China.
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6
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Whitson BA, Black SM. Ethical implications of ex vivo organ assessment and repair centers. FRONTIERS IN TRANSPLANTATION 2023; 2:1184439. [PMID: 38993885 PMCID: PMC11235233 DOI: 10.3389/frtra.2023.1184439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/08/2023] [Indexed: 07/13/2024]
Affiliation(s)
- Bryan A. Whitson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- The Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical, College of Medicine, Columbus, OH, United States
| | - Sylvester M. Black
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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7
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Expanding the Lung Donor Pool: Donation After Circulatory Death, Ex-Vivo Lung Perfusion and Hepatitis C Donors. Clin Chest Med 2023; 44:77-83. [PMID: 36774170 DOI: 10.1016/j.ccm.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
"Organ shortage remains a limiting factor in lung transplantation. Traditionally, donation after brain death has been the main source of lungs used for transplantation; however, to meet the demand of patients requiring lung transplantation it is crucial to find innovative methods for organ donation. The implementation of extended donors, lung donation after cardiac death (DCD), the use of ex-vivo lung perfusion (EVLP) systems, and more recently the acceptance of hepatitis C donors have started to close the gap between organ donors and recipients in need of lung transplantation. This article focuses on the expansion of donor lungs for transplantation after DCD, the use of EVLP in evaluating extended criteria lungs, and the use of lung grafts from donors with hepatitis C."
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8
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Diagnostic and Therapeutic Implications of Ex Vivo Lung Perfusion in Lung Transplantation: Potential Benefits and Inherent Limitations. Transplantation 2023; 107:105-116. [PMID: 36508647 DOI: 10.1097/tp.0000000000004414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Ex vivo lung perfusion (EVLP), a technique in which isolated lungs are continually ventilated and perfused at normothermic temperature, is emerging as a promising platform to optimize donor lung quality and increase the lung graft pool. Over the past few decades, the EVLP technique has become recognized as a significant achievement and gained much attention in the field of lung transplantation. EVLP has been demonstrated to be an effective platform for various targeted therapies to optimize donor lung function before transplantation. Additionally, some physical parameters during EVLP and biological markers in the EVLP perfusate can be used to evaluate graft function before transplantation and predict posttransplant outcomes. However, despite its advantages, the clinical practice of EVLP continuously encounters multiple challenges associated with both intrinsic and extrinsic limitations. It is of utmost importance to address the advantages and disadvantages of EVLP for its broader clinical usage. Here, the pros and cons of EVLP are comprehensively discussed, with a focus on its benefits and potential approaches for overcoming the remaining limitations. Directions for future research to fully explore the clinical potential of EVLP in lung transplantation are also discussed.
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9
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Yu J, Zhang N, Zhang Z, Li Y, Gao J, Chen C, Wen Z. Exploring predisposing factors and pathogenesis contributing to injuries of donor lungs. Expert Rev Respir Med 2022; 16:1191-1203. [PMID: 36480922 DOI: 10.1080/17476348.2022.2157264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Lung transplantation (LTx) remains the only therapeutic strategy for patients with incurable lung diseases. However, its use has been severely limited by the narrow donor pool and potential concerns of inferior quality of donor lungs, which are more susceptible to external influence than other transplant organs. Multiple insults, including various causes of death and a series of perimortem events, may act together on donor lungs and eventually culminate in primary graft dysfunction (PGD) after transplantation as well as other poor short-term outcomes. AREAS COVERED This review focuses on the predisposing factors contributing to injuries to the donor lungs, specifically focusing on the pathogenesis of these injuries and their impact on post-transplant outcomes. Additionally, various maneuvers to mitigate donor lung injuries have been proposed. EXPERT OPINION The selection criteria for eligible donors vary and may be poor discriminators of lung injury. Not all transplanted lungs are in ideal condition. With the rapidly increasing waiting list for LTx, the trend of using marginal donors has become more apparent, underscoring the need to gain a deeper understanding of donor lung injuries and discover more donor resources.
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Affiliation(s)
- Jing Yu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Nan Zhang
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Zhiyuan Zhang
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Yuping Li
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Jiameng Gao
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Zongmei Wen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
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10
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Miller CL, O JM, Allan JS, Madsen JC. Novel approaches for long-term lung transplant survival. Front Immunol 2022; 13:931251. [PMID: 35967365 PMCID: PMC9363671 DOI: 10.3389/fimmu.2022.931251] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Allograft failure remains a major barrier in the field of lung transplantation and results primarily from acute and chronic rejection. To date, standard-of-care immunosuppressive regimens have proven unsuccessful in achieving acceptable long-term graft and patient survival. Recent insights into the unique immunologic properties of lung allografts provide an opportunity to develop more effective immunosuppressive strategies. Here we describe advances in our understanding of the mechanisms driving lung allograft rejection and highlight recent progress in the development of novel, lung-specific strategies aimed at promoting long-term allograft survival, including tolerance.
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Affiliation(s)
- Cynthia L. Miller
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - Jane M. O
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - James S. Allan
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Joren C. Madsen
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
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11
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High Doses of Inhaled Nitric Oxide as an Innovative Antimicrobial Strategy for Lung Infections. Biomedicines 2022; 10:biomedicines10071525. [PMID: 35884830 PMCID: PMC9312466 DOI: 10.3390/biomedicines10071525] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/06/2022] [Accepted: 06/15/2022] [Indexed: 11/24/2022] Open
Abstract
Since the designation of nitric oxide as “Molecule of the Year” in 1992, the scientific and clinical discoveries concerning this biomolecule have been greatly expanding. Currently, therapies enhancing the release of endogenous nitric oxide or the direct delivery of the exogenous compound are recognized as valuable pharmacological treatments in several disorders. In particular, the administration of inhaled nitric oxide is routinely used to treat patients with pulmonary hypertension or refractory hypoxemia. More recently, inhaled nitric oxide has been studied as a promising antimicrobial treatment strategy against a range of pathogens, including resistant bacterial and fungal infections of the respiratory system. Pre-clinical and clinical findings have demonstrated that, at doses greater than 160 ppm, nitric oxide has antimicrobial properties and can be used to kill a broad range of infectious microorganisms. This review focused on the mechanism of action and current evidence from in vitro studies, animal models and human clinical trials of inhaled high-dose nitric oxide as an innovative antimicrobial therapy for lung infections.
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12
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Ex Vivo Lung Perfusion: A Review of Current and Future Application in Lung Transplantation. Pulm Ther 2022; 8:149-165. [PMID: 35316525 PMCID: PMC9098710 DOI: 10.1007/s41030-022-00185-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/25/2022] [Indexed: 12/23/2022] Open
Abstract
The number of waitlisted lung transplant candidates exceeds the availability of donor organs. Barriers to utilization of donor lungs include suboptimal lung allograft function, long ischemic times due to geographical distance between donor and recipient, and a wide array of other logistical and medical challenges. Ex vivo lung perfusion (EVLP) is a modality that allows donor lungs to be evaluated in a closed circuit outside of the body and extends lung donor assessment prior to final acceptance for transplantation. EVLP was first utilized successfully in 2001 in Lund, Sweden. Since its initial use, EVLP has facilitated hundreds of lung transplants that would not have otherwise happened. EVLP technology continues to evolve and improve, and currently there are multiple commercially available systems, and more under investigation worldwide. Although barriers to universal utilization of EVLP exist, the possibility for more widespread adaptation of this technology abounds. Not only does EVLP have diagnostic capabilities as an organ monitoring device but also the therapeutic potential to improve lung allograft quality when specific issues are encountered. Expanded treatment potential includes the use of immunomodulatory treatment to reduce primary graft dysfunction, as well as targeted antimicrobial therapy to treat infection. In this review, we will highlight the historical development, the current state of utilization/capability, and the future promise of this technology.
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13
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Michaelsen VS, Ribeiro RVP, Brambate E, Ali A, Wang A, Pires L, Kawashima M, Zhang Y, Gazzalle A, Keshavjee S, Del Sorbo L, Cypel M. A novel pre-clinical strategy to deliver antimicrobial doses of inhaled nitric oxide. PLoS One 2021; 16:e0258368. [PMID: 34644318 PMCID: PMC8513841 DOI: 10.1371/journal.pone.0258368] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/25/2021] [Indexed: 11/26/2022] Open
Abstract
Effective treatment of respiratory infections continues to be a major challenge. In high doses (≥160 ppm), inhaled Nitric Oxide (iNO) has been shown to act as a broad-spectrum antimicrobial agent, including its efficacy in vitro for coronavirus family. However, the safety of prolonged in vivo implementation of high-dose iNO therapy has not been studied. Herein we aim to explore the feasibility and safety of delivering continuous high-dose iNO over an extended period of time using an in vivo animal model. Yorkshire pigs were randomized to one of the following two groups: group 1, standard ventilation; and group 2, standard ventilation + continuous iNO 160 ppm + methylene blue (MB) as intravenous bolus, whenever required, to maintain metHb <6%. Both groups were ventilated continuously for 6 hours, then the animals were weaned from sedation, mechanical ventilation and followed for 3 days. During treatment, and on the third post-operative day, physiologic assessments were performed to monitor lung function and other significative markers were assessed for potential pulmonary or systemic injury. No significant change in lung function, or inflammatory markers were observed during the study period. Both gas exchange function, lung tissue cytokine analysis and histology were similar between treated and control animals. During treatment, levels of metHb were maintained <6% by administration of MB, and NO2 remained <5 ppm. Additionally, considering extrapulmonary effects, no significant changes were observed in biochemistry markers. Our findings showed that high-dose iNO delivered continuously over 6 hours with adjuvant MB is clinically feasible and safe. These findings support the development of investigations of continuous high-dose iNO treatment of respiratory tract infections, including SARS-CoV-2.
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Affiliation(s)
- Vinicius S. Michaelsen
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rafaela V. P. Ribeiro
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Edson Brambate
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aadil Ali
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aizhou Wang
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Layla Pires
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mitsuaki Kawashima
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Yu Zhang
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Anajara Gazzalle
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
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14
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Bath PM, Coleman CM, Gordon AL, Lim WS, Webb AJ. Nitric oxide for the prevention and treatment of viral, bacterial, protozoal and fungal infections. F1000Res 2021; 10:536. [PMID: 35685687 PMCID: PMC9171293 DOI: 10.12688/f1000research.51270.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 12/18/2023] Open
Abstract
Although the antimicrobial potential of nitric oxide (NO) is widely published, it is little used clinically. NO is a key signalling molecule modulating vascular, neuronal, inflammatory and immune responses. Endogenous antimicrobial activity is largely mediated by high local NO concentrations produced by cellular inducible nitric oxide synthase, and by derivative reactive nitrogen oxide species including peroxynitrite and S-nitrosothiols. NO may be taken as dietary substrate (inorganic nitrate, L-arginine), and therapeutically as gaseous NO, and transdermal, sublingual, oral, intranasal and intravenous nitrite or nitrate. Numerous preclinical studies have demonstrated that NO has generic static and cidal activities against viruses (including β-coronaviruses such as SARS-CoV-2), bacteria, protozoa and fungi/yeasts in vitro. Therapeutic effects have been seen in animal models in vivo, and phase II trials have demonstrated that NO donors can reduce microbial infection. Nevertheless, excess NO, as occurs in septic shock, is associated with increased morbidity and mortality. In view of the dose-dependent positive and negative effects of NO, safety and efficacy trials of NO and its donors are needed for assessing their role in the prevention and treatment of infections. Trials should test dietary inorganic nitrate for pre- or post-exposure prophylaxis and gaseous NO or oral, topical or intravenous nitrite and nitrate for treatment of mild-to-severe infections, including due to SARS-CoV-2 (COVID-19). This review summarises the evidence base from in vitro, in vivo and early phase clinical studies of NO activity in viral, bacterial, protozoal and fungal infections.
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Affiliation(s)
- Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, Notts, NG7 2UH, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, Notts, NG7 2UH, UK
| | - Christopher M. Coleman
- Division of Infection, Immunity and Microbes, School of Life Sciences, University of Nottingham, Nottingham, Notts, NG7 2UH, UK
| | - Adam L. Gordon
- Unit of Injury, Inflammation and Recovery Sciences, University of Nottingham, Derby, Derbyshire, DE22 3NE, UK
- NIHR Applied Research Collaboration-East Midlands (ARC-EM), Nottingham, Notts, UK
| | - Wei Shen Lim
- Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Andrew J. Webb
- Clinical Pharmacology, School of Cardiovascular Medicine & Sciences, Kings College London British Heart Foundation Centre of Research Excellence, St Thomas' Hospital, London, SE1 7EH, UK
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Pushing the Envelope for Donor Lungs. Semin Respir Crit Care Med 2021; 42:357-367. [PMID: 34030199 DOI: 10.1055/s-0041-1729859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The shortage of organ donors remains the major limiting factor in lung transplant, with the number of patients on the waiting list largely exceeding the number of available organ donors. Another issue is the low utilization rate seen in some types of donors. Therefore, novel strategies are continuously being explored to increase the donor pool. Advanced age, smoking history, positive serologies, and size mismatch are common criteria that decrease the rate of use when it comes to organ utilization. Questioning these limitations is one of the purposes of this review. Challenging these limitations by adapting novel donor management strategies could help to increase the rate of suitable lungs for transplantation while still maintaining good outcomes. A second goal is to present the latest advances in organ donation after controlled and uncontrolled cardiac death, and also on how to improve these lungs on ex vivo platforms for assessment and future specific therapies. Finally, pushing the limit of the donor envelope also means reviewing some of the recent improvements made in lung preservation itself, as well as upcoming experimental research fields. In summary, donor lung optimization refers to a global care strategy to increase the total numbers of available allografts, and preserve or improve organ quality without paying the price of early-, mid-, or long-term negative outcomes after transplantation.
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Benazzo A, Hoetzenecker K. Commentary: Say yes to NO! J Thorac Cardiovasc Surg 2021; 163:850-851. [PMID: 33451842 DOI: 10.1016/j.jtcvs.2020.12.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Alberto Benazzo
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
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McCurry KR, Okamoto T, Ayyat KS. Commentary: To use or not to use…Is NO the answer? J Thorac Cardiovasc Surg 2020; 163:851-852. [PMID: 33518386 DOI: 10.1016/j.jtcvs.2020.12.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Kenneth R McCurry
- Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Transplant Center, Cleveland Clinic, Cleveland, Ohio.
| | - Toshihiro Okamoto
- Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Transplant Center, Cleveland Clinic, Cleveland, Ohio
| | - Kamal S Ayyat
- Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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