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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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Nielsen WH, Gustafsson F, Olsen PS, Hansen PB, Rossing K, Lilleør NB, Møller-Sørensen PH, Møller CH. Short-term outcomes after heart transplantation using donor hearts preserved with ex vivo perfusion. SCAND CARDIOVASC J 2023; 57:2267804. [PMID: 37822186 DOI: 10.1080/14017431.2023.2267804] [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: 05/31/2023] [Accepted: 10/01/2023] [Indexed: 10/13/2023]
Abstract
The standard Conventional Cold Storage (CCS) during heart transplantation procurement is associated with time-dependent ischemic injury to the graft, which is a significant independent risk factor for post-transplant early morbidity and mortality - especially when cold ischemic time exceeds four hours. Since 2018, Rigshospitalet (Copenhagen, Denmark) has been utilising ex vivo perfusion (Organ Care System, OCS) in selected cases. The objective of this study was to compare the short-term clinical outcomes of patients transplanted with OCS compared to CCS. Methods: This retrospective single-centre study was based on consecutive patients undergoing a heart transplant between January 2018 and April 2021. Patients were selected for the OCS group when the cold ischemic time was expected to exceed four hours. The primary outcome measure was six-month event-free survival. Results: In total, 48 patients were included in the study; nine were transplanted with an OCS heart. The two groups had no significant differences in baseline characteristics. Six-month event-free survival was 77.8% [95% CI: 54.9-100%] in the OCS group and 79.5% [95% CI: 67.8-93.2%] in the CCS group (p = 0.91). While the OCS group had a median out-of-body time that was 183 min longer (p < 0.0001), the cold ischemic time was reduced by 51 min (p = 0.007). Conclusion: In a Scandinavian setting, our data confirms that utilising OCS in heart procurement allows for a longer out-of-body time and a reduced cold ischemic time without negatively affecting safety or early post-transplant outcomes.
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Affiliation(s)
- William Herrik Nielsen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Skov Olsen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Bo Hansen
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kasper Rossing
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Nikolaj Bang Lilleør
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Hasse Møller-Sørensen
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Holdflod Møller
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kounatidis D, Brozou V, Anagnostopoulos D, Pantos C, Lourbopoulos A, Mourouzis I. Donor Heart Preservation: Current Knowledge and the New Era of Machine Perfusion. Int J Mol Sci 2023; 24:16693. [PMID: 38069017 PMCID: PMC10706714 DOI: 10.3390/ijms242316693] [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: 10/12/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023] Open
Abstract
Heart transplantation remains the conventional treatment in end-stage heart failure, with static cold storage (SCS) being the standard technique used for donor preservation. Nevertheless, prolonged cold ischemic storage is associated with the increased risk of early graft dysfunction attributed to residual ischemia, reperfusion, and rewarming damage. In addition, the demand for the use of marginal grafts requires the development of new methods for organ preservation and repair. In this review, we focus on current knowledge and novel methods of donor preservation in heart transplantation. Hypothermic or normothermic machine perfusion may be a promising novel method of donor preservation based on the administration of cardioprotective agents. Machine perfusion seems to be comparable to cold cardioplegia regarding donor preservation and allows potential repair treatments to be employed and the assessment of graft function before implantation. It is also a promising platform for using marginal organs and increasing donor pool. New pharmacological cardiac repair treatments, as well as cardioprotective interventions have emerged and could allow for the optimization of this modality, making it more practical and cost-effective for the real world of transplantation. Recently, the use of triiodothyronine during normothermic perfusion has shown a favorable profile on cardiac function and microvascular dysfunction, likely by suppressing pro-apoptotic signaling and increasing the expression of cardioprotective molecules.
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Affiliation(s)
| | | | | | | | | | - Iordanis Mourouzis
- Department of Pharmacology, National and Kapodistrian University of Athens, 11527 Athens, Greece; (D.K.); (V.B.); (D.A.); (C.P.); (A.L.)
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4
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Urban M, Castleberry AW, Siddique A, Lowes BD, Stoller DA, Lundgren SW, Um JY. Utilization of Paragonix Sherpapak Cardiac Transport System for the Preservation of Donor Hearts After Circulatory Death. Transplant Proc 2023; 55:1997-2002. [PMID: 37739830 PMCID: PMC11299485 DOI: 10.1016/j.transproceed.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/04/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Donation after circulatory death (DCD) heart transplantation is being increasingly adopted by transplant centers. The optimal method of DCD heart preservation during transport after in situ thoracoabdominal normothermic regional perfusion (TA-NRP) is not known. METHODS We evaluated our experience with the Paragonix SherpaPak Cardiac Transport System (SCTS) for the transport of DCD cardiac allografts after TA-NRP recovery between January 2021 and December 2022. We collected and evaluated donor characteristics, allograft ischemic intervals, and recipient baseline demographic and clinical variables, and short-term outcomes. RESULTS Twelve recipients received DCD grafts recovered with TA-NRP and transported in SCTS during the study period. The median age of 10 male and 2 female donors was 32 years (min 15, max 38). The median duration of functional warm ischemia was 12 minutes (min 8, max 22). Hearts were preserved in SCTS for a median of 158 minutes (min 37, max 224). Median recipient age was 61 years (min 28, max 70). Ten recipients (83%) survived to hospital discharge, with one death attributable to graft dysfunction (8%). The median vasoactive-inotropic (VIS) score at 72 hours post-transplantation of the entire cohort was 6 (min 0, max 15). The median length of intensive care unit stay in hospital survivors was 5 days (min 3, max 17) days and hospital stay 17 days (min 9, max 37). CONCLUSIONS The Paragonix SCTS provides efficacious preservation of DCD grafts for ≥3.5 hours. Organs transported with this device showed satisfactory post-transplantation function.
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Affiliation(s)
- Marian Urban
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Anthony W Castleberry
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Aleem Siddique
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Brian D Lowes
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Douglas A Stoller
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Scott W Lundgren
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - John Y Um
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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5
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Wagner MJ, Hatami S, Freed DH. Thoracic organ machine perfusion: A review of concepts with a focus on reconditioning therapies. FRONTIERS IN TRANSPLANTATION 2023; 2:1060992. [PMID: 38993918 PMCID: PMC11235380 DOI: 10.3389/frtra.2023.1060992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/06/2023] [Indexed: 07/13/2024]
Abstract
Thoracic organ transplantation, including lung, heart, and heart-lung transplants are highly regarded as gold standard treatments for patients suffering from heart failure or chronic end stage lung conditions. The relatively high prevalence of conditions necessitating thoracic organ transplants combined with the lack of available organs has resulted in many either dying or becoming too ill to receive a transplant while on the waiting list. There is a dire need to increase both the number of organs available and the utilization of such organs. Improved preservation techniques beyond static storage have shown great potential to lengthen the current period of viability of thoracic organs while outside the body, promising better utilization rates, increased donation distance, and improved matching of donors to recipients. Ex-situ organ perfusion (ESOP) can also make some novel therapeutic strategies viable, and the combination of the ESOP platform with such reconditioning therapies endeavors to better improve functional preservation of organs in addition to making more organs viable for transplantation. Given the abundance of clinical and pre-clinical studies surrounding reconditioning of thoracic organs in combination with ESOP, we summarize in this review important concepts and research regarding thoracic organ machine perfusion in combination with reconditioning therapies.
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Affiliation(s)
| | - Sanaz Hatami
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Darren H Freed
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Physiology, University of Alberta, Edmonton, AB, Canada
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
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6
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Sakota D, Kosaka R, Nagaoka E, Ohuchi K, Tahara T, Arai H, Sakanoue I, McCurry KR, Okamoto T. Left ventricular assist device mode: Co-pulse left ventricular unloading in a working mode of ex vivo heart perfusion. J Heart Lung Transplant 2023; 42:707-715. [PMID: 36931988 DOI: 10.1016/j.healun.2023.01.009] [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: 03/25/2022] [Revised: 11/10/2022] [Accepted: 01/14/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND For normothermic ex vivo heart perfusion (EVHP), a resting mode and working mode have been proposed. We newly developed a left ventricular assist device (LVAD) mode that supports heart contraction by co-pulse synchronized LVAD. METHODS Following resting mode during time 0 to 1 hour, pig hearts (n = 18) were perfused in either resting, working, or LVAD mode during time 1 to 5 hour, and then myocardial function was evaluated in working mode at 6 hour. The preservation ratio was defined as the myocardial mechanical function at 330 minute divided by the function at 75 minute. In LVAD mode, LVAD unloaded the pressure and the volume in the left ventricle in the systolic phase. RESULTS The LVAD group was significantly associated with higher preservation ratios in cardiac output (resting, 33 ± 3; working, 35 ± 5; LVAD, 76% ± 5%; p < 0.001), stroke work, dP/dt maximum, and dP/dt minimum compared with the other groups. Glucose consumption was significantly reduced in the resting group. The LVAD group was significantly associated with higher myocardial oxygen consumption (resting, 2.2 ± 0.3; working; 4.6 ± 0.5; LVAD, 6.1 ± 0.5 mL O2/min/100 g, p < 0.001) and higher adenosine triphosphate (ATP) levels (resting, 1.1 ± 0.1; working, 0.7 ± 0.1; LVAD, 1.6 ± 0.2 μmol/g, p = 0.001) compared with the others. CONCLUSION These data suggest that myocardial mechanical function was better preserved in LVAD mode than in resting and working modes. Although our data suggested similar glycolysis activity in the LVAD and working groups, the higher final ATP in the LVAD group might be explained by reduced external work in LVAD.
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Affiliation(s)
- Daisuke Sakota
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan.
| | - Ryo Kosaka
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan
| | - Eiki Nagaoka
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Katsuhiro Ohuchi
- Department of Advanced Surgical Technology Research and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomoki Tahara
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ichiro Sakanoue
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Transplant Center, Cleveland Clinic, Cleveland, Ohio
| | - Kenneth R McCurry
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Transplant Center, Cleveland Clinic, Cleveland, Ohio
| | - Toshihiro Okamoto
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Transplant Center, Cleveland Clinic, Cleveland, Ohio.
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7
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Roesel MJ, Wiegmann B, Ius F, Knosalla C, Iske J. The role of ex-situ perfusion for thoracic organs. Curr Opin Organ Transplant 2022; 27:466-473. [PMID: 35950888 DOI: 10.1097/mot.0000000000001008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Ex-situ machine perfusion for both heart (HTx) and lung transplantation (LuTx) reduces ischemia-reperfusion injury (IRI), allows for greater flexibility in geographical donor management, continuous monitoring, organ assessment for extended evaluation, and potential reconditioning of marginal organs. In this review, we will delineate the impact of machine perfusion, characterize novel opportunities, and outline potential challenges lying ahead to improve further implementation. RECENT FINDINGS Due to the success of several randomized controlled trials (RCT), comparing cold storage to machine perfusion in HTx and LuTx, implementation and innovation continues. Indeed, it represents a promising interface for organ-specific therapies targeting IRI, allo-immune responses, and graft reconditioning. These mostly experimental efforts range from genetic approaches and nanotechnology to cellular therapies, involving mesenchymal stem cell application. Despite tremendous potential, prior to clinical transition, more data is needed. SUMMARY Collectively, machine perfusion constitutes the vanguard in thoracic organ transplantation research with extensive potential for expanding the donor pool, enhancing transplant outcomes as well as developing novel therapy approaches.
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Affiliation(s)
- Maximilian J Roesel
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
- Institute of Medical Immunology, Charite Universitaetsmedizin Berlin, Berlin, Germany
| | - Bettina Wiegmann
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- DFG Priority Program SPP 2014, German Research Foundation, Bonn, Germany
| | - Fabio Ius
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Jasper Iske
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
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8
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Alomari M, Garg P, Yazji JH, Wadiwala IJ, Alamouti-fard E, Hussain MWA, Elawady MS, Jacob S. Is the Organ Care System (OCS) Still the First Choice With Emerging New Strategies for Donation After Circulatory Death (DCD) in Heart Transplant? Cureus 2022; 14:e26281. [PMID: 35754437 PMCID: PMC9229932 DOI: 10.7759/cureus.26281] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 12/14/2022] Open
Abstract
The scarcity of donor hearts continues to be a challenge in transplants for advanced heart failure patients. With an increasing number of patients on the waiting list for a heart transplant, the discrepancy in the number between donors and recipients is gradually increasing and poses a new challenge that plagues the healthcare systems when it comes to the heart. Several technologies have been developed to expand the donor pool in recent years. One such method is the organ care system (OCS). The standard method of organ preservation is the static cold storage (SCS) method which allows up to four hours of safe preservation of the heart. However, beyond four hours of cold ischemia, the incidence of primary graft dysfunction increases significantly. OCS keeps the heart perfused close to the physiological state beyond the four hours with superior results, which allows us to travel further and longer distances, leading to expansion in the donor pool. In this review, we discuss the OCS system, its advantages, and shortcomings.
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Normothermic Ex Situ Heart Perfusion With the Organ Care System for Cardiac Transplantation: A Meta-analysis. Transplantation 2022; 106:1745-1753. [PMID: 35618669 DOI: 10.1097/tp.0000000000004167] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Heart transplantation (HTx) is, at present, the most effective therapy for end-stage heart failure patients; however, the number of patients on the waiting list is rising globally, further increasing the gap between demand and supply of donors for HTx. First studies using the Organ Care System (OCS) for normothermic machine perfusion show promising results yet are limited in sample size. This article presents a meta-analysis of heart donation either after brain death (OCS-DBD) or circulatory death (OCS-DCD) on using OCS versus static cold storage used for HTx. METHODS A systematic literature search was performed for articles discussing the use of normothermic ex situ heart perfusion in adult patients. Thirty-day survival outcomes were pooled, and odds ratios were calculated using random-effects models. Long-term survival was visualized with Kaplan-Meier curves, hazard ratios were calculated and pooled using fixed-effects models, and secondary outcomes were analyzed. RESULTS A total of 12 studies were included, with 741 patients undergoing HTx, of which 260 with the OCS (173 DBD and 87 DCD). No differences were found between the 3 groups for early and late survival outcomes or for secondary outcomes. CONCLUSIONS OCS outcomes, for both DBD and DCD hearts, appeared similar as for static cold storage. Therefore, OCS is a safe and effective technique to enlarge the cardiac donor pool in both DBD and DCD, with additional benefits for long-distance transport and surgically complex procedures.
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10
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Pahuja M, Case BC, Molina EJ, Waksman R. Overview of the FDA's Circulatory System Devices Panel virtual meeting on the TransMedics Organ Care System (OCS) Heart - portable extracorporeal heart perfusion and monitoring system. Am Heart J 2022; 247:90-99. [PMID: 35150637 DOI: 10.1016/j.ahj.2022.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/11/2022] [Accepted: 02/03/2022] [Indexed: 11/18/2022]
Abstract
There are a limited number of donor hearts available for transplantation every year, and an even lower number of these hearts actually undergo transplantation. One of the barriers to utilizing donor hearts is the inferior outcomes associated with prolonged ischemic times. There have been increasing attempts to develop alternative techniques for prolonged storage to raise the number of heart transplants while maintaining acceptable outcomes. One such new technology utilizes continuous ex vivo perfusion of the donor heart with oxygenated blood and allows for prolonged storage and preservation times. The TransMedics Organ Care System (OCS) Heart (TransMedics; Andover, MA) claims to optimize the condition of the donor organs by preserving them in a warm, functioning environment. On April 6, 2021, the United States Food and Drug Administration convened a virtual meeting of the Circulatory System Devices Panel of the Medical Devices Advisory Committee to provide guidance on the TransMedics OCS Heart System's application for premarket approval. This application was subsequently approved on September 7, 2021. We provide an overview of the meeting, including the results of the clinical trials that were presented.
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Affiliation(s)
- Mohit Pahuja
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Ezequiel J Molina
- Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
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11
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Truby LK, Casalinova S, Patel CB, Agarwal R, Holley CL, Mentz RJ, Milano C, Bryner B, Schroder JN, Devore AD. Donation After Circulatory Death in Heart Transplantation: History, Outcomes, Clinical Challenges, and Opportunities to Expand the Donor Pool. J Card Fail 2022; 28:1456-1463. [PMID: 35447338 DOI: 10.1016/j.cardfail.2022.03.353] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/15/2022]
Abstract
Heart transplantation remains the gold-standard therapy for end-stage heart failure; the expected median survival range is 12-13 years. More than 30,000 heart transplants have been performed globally in the past decade alone. With advances in medical and surgical therapies for heart failure, including durable left ventricular assist devices, an increasing number of patients are living with end-stage disease. Last year alone, more than 2500 patients were added to the heart-transplant waitlist in the United States. Despite recent efforts to expand the donor pool, including an increase in transplantation of hepatitis C-positive and extended-criteria donors, supply continues to fall short of demand. Donation after circulatory death (DCD), defined by irreversible cardiopulmonary arrest rather than donor brain death, is widely used in other solid-organ transplants, including kidney and liver, but has not been widely adopted in heart transplantation. However, resurging interest in DCD donation and the introduction of ex vivo perfusion technology has catalyzed recent clinical trials and the development of DCD heart-transplantation programs. Herein, we review the history of DCD heart transplantation, describe the currently used procurement protocols for it and examine clinical challenges and outcomes of such a procedure.
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Affiliation(s)
- Lauren K Truby
- From the Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Sarah Casalinova
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Richa Agarwal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Christopher L Holley
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Carmelo Milano
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Benjamin Bryner
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Adam D Devore
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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12
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Production of Living Myocardial Slices from Circulatory Death Hearts after Ex-Vivo Heart Perfusion. JTCVS Tech 2022; 13:128-130. [PMID: 35711226 PMCID: PMC9196990 DOI: 10.1016/j.xjtc.2022.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/30/2022] [Indexed: 11/21/2022] Open
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13
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Gao Z, Namsrai B, Han Z, Joshi P, Rao JS, Ravikumar V, Sharma A, Ring HL, Idiyatullin D, Magnuson EC, Iaizzo PA, Tolkacheva EG, Garwood M, Rabin Y, Etheridge M, Finger EB, Bischof JC. Vitrification and Rewarming of Magnetic Nanoparticle-Loaded Rat Hearts. ADVANCED MATERIALS TECHNOLOGIES 2022; 7:2100873. [PMID: 35668819 PMCID: PMC9164386 DOI: 10.1002/admt.202100873] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Indexed: 05/24/2023]
Abstract
To extend the preservation of donor hearts beyond the current 4-6 h, this paper explores heart cryopreservation by vitrification-cryogenic storage in a glass-like state. While organ vitrification is made possible by using cryoprotective agents (CPA) that inhibit ice during cooling, failure occurs during convective rewarming due to slow and non-uniform rewarming which causes ice crystallization and/or cracking. Here an alternative, "nanowarming", which uses silica-coated iron oxide nanoparticles (sIONPs) perfusion loaded through the vasculature is explored, that allows a radiofrequency coil to rewarm the organ quickly and uniformly to avoid convective failures. Nanowarming has been applied to cells and tissues, and a proof of principle study suggests it is possible in the heart, but proper physical and biological characterization especially in organs is still lacking. Here, using a rat heart model, controlled machine perfusion loading and unloading of CPA and sIONPs, cooling to a vitrified state, and fast and uniform nanowarming without crystallization or cracking is demonstrated. Further, nanowarmed hearts maintain histologic appearance and endothelial integrity superior to convective rewarming and indistinguishable from CPA load/unload control hearts while showing some promising organ-level (electrical) functional activity. This work demonstrates physically successful heart vitrification and nanowarming and that biological outcomes can be expected to improve by reducing or eliminating CPA toxicity during loading and unloading.
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Affiliation(s)
- Zhe Gao
- Department of Mechanical Engineering, University of Minnesota, 111 Church St. SE., Minneapolis, MN 55455, USA
| | - Baterdene Namsrai
- Department of Surgery, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Zonghu Han
- Department of Mechanical Engineering, University of Minnesota, 111 Church St. SE., Minneapolis, MN 55455, USA
| | - Purva Joshi
- Department of Mechanical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213, USA
| | - Joseph Sushil Rao
- Department of Surgery, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Vasanth Ravikumar
- Department of Biomedical Engineering, University of Minnesota, 312 Church St. SE, Minneapolis, MN 55455, USA
| | - Anirudh Sharma
- Department of Mechanical Engineering, University of Minnesota, 111 Church St. SE., Minneapolis, MN 55455, USA
| | - Hattie L Ring
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, 2021 6th Street S.E. Minneapolis, Minneapolis, MN 55455, USA
| | - Djaudat Idiyatullin
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, 2021 6th Street S.E. Minneapolis, Minneapolis, MN 55455, USA
| | - Elliott C Magnuson
- Department of Mechanical Engineering, University of Minnesota, 111 Church St. SE., Minneapolis, MN 55455, USA
| | - Paul A Iaizzo
- Department of Surgery, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Elena G Tolkacheva
- Department of Biomedical Engineering, University of Minnesota, 312 Church St. SE, Minneapolis, MN 55455, USA
| | - Michael Garwood
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, 2021 6th Street S.E. Minneapolis, Minneapolis, MN 55455, USA
| | - Yoed Rabin
- Department of Mechanical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213, USA
| | - Michael Etheridge
- Department of Mechanical Engineering, University of Minnesota, 111 Church St. SE., Minneapolis, MN 55455, USA
| | - Erik B Finger
- Department of Surgery, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - John C Bischof
- Department of Mechanical Engineering, University of Minnesota, 111 Church St. SE., Minneapolis, MN 55455, USA
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Ex vivo perfusion of the donor heart: Preliminary experience in high-risk transplantations. Arch Cardiovasc Dis 2021; 114:715-726. [PMID: 34620574 DOI: 10.1016/j.acvd.2021.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/07/2021] [Accepted: 07/15/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The number of heart transplantations (HTs) has decreased in France since 2017 (-5%/year) despite a stable rate of patients referred on the waiting list. Ex vivo heart perfusion (EVHP) is an innovative approach for organ preservation, reducing graft ischaemic time and facilitating continuous organ monitoring before transplantation. AIM To report our preliminary experience of seven donor hearts preserved with EVHP, including the first heart resuscitated after circulatory-determined death in France. METHODS Seven hearts were procured from donation after brain death (DBD) for HT or donation after circulatory-determined death (DCD) for research purposes (Protocol PFS20-004, Agence de la Biomédecine, La Plaine Saint-Denis, France). All grafts were preserved using the Organ Care System® (TransMedics Inc., Andover, MA, USA) for normothermic EVHP. Perfusion parameters were adjusted to achieve stable or decreasing arterial lactate trend consistent with suitability for organ transplantation. RESULTS Indications for EVHP were assessment of a marginal graft in four cases, prolonged preservation in two cases (anticipated duration for retrieval of recipient's heart>3hours) and resuscitation after circulatory-determined death in one case. Median duration of EVHP was 270 (interquartile range 216-343) minutes. five were transplanted, with a median ex situ preservation time (ischaemic time+EVHP time) of 334 (interquartile range 326-444) minutes. The two other grafts were discarded for HT. Three recipients had extracorporeal life support after HT, and presented complete cardiac recovery within a week after HT. One patient died at day 11 because of septic shock. The 3-month survival rate was 75% among recipients. Three months after HT, the left ventricular ejection fraction was>60% in all cases. CONCLUSIONS EVHP enabled safe prolonged preservation and assessment of marginal grafts. This approach provides an opportunity to expand the donor pool by resuscitating grafts from donors with extended criteria, including controlled DCD.
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Pinnelas R, Kobashigawa JA. Ex vivo normothermic perfusion in heart transplantation: a review of the TransMedics ® Organ Care System. Future Cardiol 2021; 18:5-15. [PMID: 34503344 DOI: 10.2217/fca-2021-0030] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Cardiac transplantation is the gold standard for treatment for select patients with end-stage heart failure, yet donor supply is limited. Ex vivo machine perfusion is an emerging technology capable of safely preserving organs and expanding the viable donor pool. The TransMedics® Organ Care System™ is an investigational device which mimics physiologic conditions while maintaining the heart in a warm, beating state rather than cold storage. The use of Organ Care System allows increased opportunities for using organs from marginal donors, distant procurement sites, donation after cardiac death, and in recipients with complex anatomy. In the future, bioengineering technologies including use of mesenchymal stem cells, viral vector delivery of gene therapy, and alternate devices may further broaden the field of ex vivo machine perfusion.
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Sampaio-Pinto V, Janssen J, Chirico N, Serra M, Alves PM, Doevendans PA, Voets IK, Sluijter JPG, van Laake LW, van Mil A. A Roadmap to Cardiac Tissue-Engineered Construct Preservation: Insights from Cells, Tissues, and Organs. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2021; 33:e2008517. [PMID: 34048090 DOI: 10.1002/adma.202008517] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/15/2021] [Indexed: 06/12/2023]
Abstract
Worldwide, over 26 million patients suffer from heart failure (HF). One strategy aspiring to prevent or even to reverse HF is based on the transplantation of cardiac tissue-engineered (cTE) constructs. These patient-specific constructs aim to closely resemble the native myocardium and, upon implantation on the diseased tissue, support and restore cardiac function, thereby preventing the development of HF. However, cTE constructs off-the-shelf availability in the clinical arena critically depends on the development of efficient preservation methodologies. Short- and long-term preservation of cTE constructs would enable transportation and direct availability. Herein, currently available methods, from normothermic- to hypothermic- to cryopreservation, for the preservation of cardiomyocytes, whole-heart, and regenerative materials are reviewed. A theoretical foundation and recommendations for future research on developing cTE construct specific preservation methods are provided. Current research suggests that vitrification can be a promising procedure to ensure long-term cryopreservation of cTE constructs, despite the need of high doses of cytotoxic cryoprotective agents. Instead, short-term cTE construct preservation can be achieved at normothermic or hypothermic temperatures by administration of protective additives. With further tuning of these promising methods, it is anticipated that cTE construct therapy can be brought one step closer to the patient.
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Affiliation(s)
- Vasco Sampaio-Pinto
- Department of Cardiology, Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Regenerative Medicine Center, University Medical Center Utrecht, Uppsalalaan 8, Utrecht, 3584 CT, The Netherlands
| | - Jasmijn Janssen
- Department of Cardiology, Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Regenerative Medicine Center, University Medical Center Utrecht, Uppsalalaan 8, Utrecht, 3584 CT, The Netherlands
| | - Nino Chirico
- Department of Cardiology, Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Regenerative Medicine Center, University Medical Center Utrecht, Uppsalalaan 8, Utrecht, 3584 CT, The Netherlands
| | - Margarida Serra
- IBET, Instituto de Biologia Experimental e Tecnológica, Apartado 12, Oeiras, 2781-901, Portugal
- Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa, Av. da República, Oeiras, 2780-157, Portugal
| | - Paula M Alves
- IBET, Instituto de Biologia Experimental e Tecnológica, Apartado 12, Oeiras, 2781-901, Portugal
- Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa, Av. da República, Oeiras, 2780-157, Portugal
| | - Pieter A Doevendans
- Department of Cardiology, Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Netherlands Heart Institute, P.O. Box 19258, Utrecht, 3501 DG, The Netherlands
| | - Ilja K Voets
- Laboratory of Self-Organizing Soft Matter, Department of Chemical Engineering and Chemistry & Institute of Complex Molecular Systems (ICMS), Eindhoven University of Technology (TUE), Groene Loper 3, Eindhoven, 5612 AE, The Netherlands
| | - Joost P G Sluijter
- Department of Cardiology, Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Regenerative Medicine Center, University Medical Center Utrecht, Uppsalalaan 8, Utrecht, 3584 CT, The Netherlands
| | - Linda W van Laake
- Department of Cardiology, Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Regenerative Medicine Center, University Medical Center Utrecht, Uppsalalaan 8, Utrecht, 3584 CT, The Netherlands
| | - Alain van Mil
- Department of Cardiology, Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Regenerative Medicine Center, University Medical Center Utrecht, Uppsalalaan 8, Utrecht, 3584 CT, The Netherlands
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McEvoy CM, Clotet-Freixas S, Tokar T, Pastrello C, Reid S, Batruch I, RaoPeters AAE, Kaths JM, Urbanellis P, Farkona S, Van JAD, Urquhart BL, John R, Jurisica I, Robinson LA, Selzner M, Konvalinka A. Normothermic Ex-vivo Kidney Perfusion in a Porcine Auto-Transplantation Model Preserves the Expression of Key Mitochondrial Proteins: An Unbiased Proteomics Analysis. Mol Cell Proteomics 2021; 20:100101. [PMID: 34033948 PMCID: PMC8253910 DOI: 10.1016/j.mcpro.2021.100101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/19/2021] [Indexed: 12/17/2022] Open
Abstract
Normothermic ex-vivo kidney perfusion (NEVKP) results in significantly improved graft function in porcine auto-transplant models of donation after circulatory death injury compared with static cold storage (SCS); however, the molecular mechanisms underlying these beneficial effects remain unclear. We performed an unbiased proteomics analysis of 28 kidney biopsies obtained at three time points from pig kidneys subjected to 30 min of warm ischemia, followed by 8 h of NEVKP or SCS, and auto-transplantation. 70/6593 proteins quantified were differentially expressed between NEVKP and SCS groups (false discovery rate < 0.05). Proteins increased in NEVKP mediated key metabolic processes including fatty acid ß-oxidation, the tricarboxylic acid cycle, and oxidative phosphorylation. Comparison of our findings with external datasets of ischemia-reperfusion and other models of kidney injury confirmed that 47 of our proteins represent a common signature of kidney injury reversed or attenuated by NEVKP. We validated key metabolic proteins (electron transfer flavoprotein subunit beta and carnitine O-palmitoyltransferase 2, mitochondrial) by immunoblotting. Transcription factor databases identified members of the peroxisome proliferator-activated receptors (PPAR) family of transcription factors as the upstream regulators of our dataset, and we confirmed increased expression of PPARA, PPARD, and RXRA in NEVKP with reverse transcription polymerase chain reaction. The proteome-level changes observed in NEVKP mediate critical metabolic pathways. These effects may be coordinated by PPAR-family transcription factors and may represent novel therapeutic targets in ischemia-reperfusion injury.
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Affiliation(s)
- Caitriona M McEvoy
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Soham and Shaila Ajmera Family Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
| | - Sergi Clotet-Freixas
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Tomas Tokar
- Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Chiara Pastrello
- Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Shelby Reid
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Ihor Batruch
- Department of Laboratory Medicine and Pathobiology, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Adrien A E RaoPeters
- Department of Physiology and Pharmacology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - J Moritz Kaths
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Essen, Germany
| | - Peter Urbanellis
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Sofia Farkona
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Julie A D Van
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Bradley L Urquhart
- Department of Physiology and Pharmacology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Rohan John
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Igor Jurisica
- Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Departments of Medical Biophysics and Computer Science, University of Toronto, Toronto, Ontario, Canada; Institute of Neuroimmunology, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Lisa A Robinson
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Program in Cell Biology, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Markus Selzner
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Soham and Shaila Ajmera Family Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Ana Konvalinka
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Soham and Shaila Ajmera Family Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
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18
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Sponga S, Bonetti A, Ferrara V, Beltrami AP, Isola M, Vendramin I, Finato N, Ortolani F, Livi U. Preservation by cold storage vs ex vivo normothermic perfusion of marginal donor hearts: clinical, histopathologic, and ultrastructural features. J Heart Lung Transplant 2020; 39:1408-1416. [DOI: 10.1016/j.healun.2020.08.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 07/18/2020] [Accepted: 08/31/2020] [Indexed: 02/04/2023] Open
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19
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Wang L, MacGowan GA, Ali S, Dark JH. Ex situ heart perfusion: The past, the present, and the future. J Heart Lung Transplant 2020; 40:69-86. [PMID: 33162304 DOI: 10.1016/j.healun.2020.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 01/06/2023] Open
Abstract
Despite the advancements in medical treatment, mechanical support, and stem cell therapy, heart transplantation remains the most effective treatment for selected patients with advanced heart failure. However, with an increase in heart failure prevalence worldwide, the gap between donor hearts and patients on the transplant waiting list keeps widening. Ex situ machine perfusion has played a key role in augmenting heart transplant activities in recent years by enabling the usage of donation after circulatory death hearts, allowing longer interval between procurement and implantation, and permitting the safe use of some extended-criteria donation after brainstem death hearts. This exciting field is at a hinge point, with 1 commercially available heart perfusion machine, which has been used in hundreds of heart transplantations, and a number of devices being tested in the pre-clinical and Phase 1 clinical trial stage. However, no consensus has been reached over the optimal preservation temperature, perfusate composition, and perfusion parameters. In addition, there is a lack of objective measurement for allograft quality and viability. This review aims to comprehensively summarize the lessons about ex situ heart perfusion as a platform to preserve, assess, and repair donor hearts, which we have learned from the pre-clinical studies and clinical applications, and explore its exciting potential of revolutionizing heart transplantation.
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Affiliation(s)
- Lu Wang
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Guy A MacGowan
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom; Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Simi Ali
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John H Dark
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
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20
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Yin S, Feng Z, Mo A, Ding Y, Wu J. Effect of Shenfu Injection on Isolated Empty Beating Hearts from Miniature Pigs. Braz J Cardiovasc Surg 2020; 35:484-489. [PMID: 32864928 PMCID: PMC7454632 DOI: 10.21470/1678-9741-2019-0264] [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] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To investigate the effect of Shenfu (SF) injection on donor heart preservation. METHODS Twelve pigs were randomly divided into SF group (n=6) and control group (n=6). After eight hours of perfusion, the differences in hemoglobin, the expression of Bcl-2 and BAX, and changes in the myocardial ultrastructure were compared to illustrate the effects of SF injection in heart preservation. RESULTS The differences in free hemoglobin between the SF group and the control group were statistically significant (P=0.001), and there was significant interaction of groups with times (P=0.019), but the perfusion time may not be associated with the hemoglobin concentration (P=0.616). According to Western blotting analysis, the expression of Bcl-2 was higher in the SF group than in the control group, while the expression of BAX was not different between the two groups. As to ultrastructural changes, both groups exhibited mitochondrial swelling and myofilament lysis, but the degree of damage in the SF group was smaller. CONCLUSION Our study suggests that the application of SF injection for heart preservation may protect against cardiomyocytes and erythrocytes apoptosis, and Bcl-2 protein may play a role in these physiological processes.
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Affiliation(s)
- Shijie Yin
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Traditional Chinese Medical University, Nanning, Guangxi, People's Republic of China
| | - Zhiqiang Feng
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Traditional Chinese Medical University, Nanning, Guangxi, People's Republic of China
| | - Ansheng Mo
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Traditional Chinese Medical University, Nanning, Guangxi, People's Republic of China
| | - Yi Ding
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Traditional Chinese Medical University, Nanning, Guangxi, People's Republic of China
| | - Jun Wu
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Traditional Chinese Medical University, Nanning, Guangxi, People's Republic of China
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21
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Abstract
Injuries sustained by donor heart and lung allografts during the transplantation process are multiple and cumulative. Optimization of allograft function plays an essential role in short- and long-term outcomes after transplantation. Therapeutic targets to prevent or attenuate injury are present in the donor, the preservation process, during transplantation, and in postoperative management of the recipient. The newest and most promising methods of optimizing donor heart and lung allografts are found in alternative preservation strategies, which enable functional assessment of donor organs and provide a modality to initiate therapies for injured allografts or prevent injury during reperfusion in recipients.
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Affiliation(s)
- Sue A Braithwaite
- Department of Anesthesiology, University Medical Center Utrecht, Mail Stop Q04.2.317, Postbus 85500, Utrecht 3508 GA, The Netherlands.
| | - Niels P van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Room E03.511, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
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22
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Intermittent application of external positive pressure helps to preserve organ viability during ex vivo perfusion and culture. J Artif Organs 2019; 23:36-45. [PMID: 31617028 PMCID: PMC7046602 DOI: 10.1007/s10047-019-01141-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 10/05/2019] [Indexed: 12/03/2022]
Abstract
The perfusion of medium through blood vessels allows the preservation of donor organs and culture of bioengineered organs. However, tissue damage due to inadequate perfusion remains a problem. We evaluated whether intermittent external pressurization would improve the perfusion and viability of organs in culture. A bioreactor system was used to perfuse and culture rat small intestine and femoral muscle preparations. Intermittent positive external pressure (10 mmHg) was applied for 20 s at intervals of 20 s. Intermittent pressurization resulted in uniform perfusion of small intestine preparations and minimal tissue damage after 20 h of perfusion, whereas non-pressurized (control) preparations exhibited significantly worse perfusion of the upper surface than the lower surface and histologic evidence of tissue damage. Longer term studies were undertaken in luciferase-expressing rat femoral muscle preparations. Compared with non-pressurized controls, intermittent pressurization led to better perfusion throughout the 14-day experimental period, improved organ viability as indicated by a higher bioluminescence intensity after perfusion with luciferin, and reduced levels of tissue necrosis with better preservation of vascular structures and skeletal muscle nuclei (histologic analyses). Therefore, intermittent application of external positive pressure improved the perfusion of small intestine and skeletal muscle preparations and enhanced tissue viability when compared with controls. We anticipate that this innovative perfusion technique could be used to improve the preservation of donor organs and culture of bioengineered organs.
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Abstract
IMPACT STATEMENT Over the past several decades, ex vivo perfusion has emerged as a promising technology for the assessment, preservation, and recovery of donor organs. Many exciting pre-clinical findings have now been translated to clinical use, and successful transplantation following ex vivo perfusion has been achieved for heart, lung, and liver. While machine perfusion provides distinct advantages over traditional cold preservation, many challenges remain, including that of long-term (multi-day) ex vivo support. Here, we provide an overview of the current status of ex vivo machine perfusion in the pre-clinical and clinical setting and share our perspective on the future direction of the field.
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Affiliation(s)
- Meghan Pinezich
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
- Department of Medicine, Columbia University, New York NY 10032, USA
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25
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Quintini C, Martins PN, Shah S, Killackey M, Reed A, Guarrera J, Axelrod DA. Implementing an innovated preservation technology: The American Society of Transplant Surgeons' (ASTS) Standards Committee White Paper on Ex Situ Liver Machine Perfusion. Am J Transplant 2018; 18:1865-1874. [PMID: 29791060 DOI: 10.1111/ajt.14945] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/15/2018] [Accepted: 05/15/2018] [Indexed: 01/25/2023]
Abstract
The pervasive shortage of deceased donor liver allografts contributes to significant waitlist mortality despite efforts to increase organ donation. Ex vivo liver perfusion appears to enhance preservation of donor organs, extending viability and potentially evaluating function in organs previously considered too high risk for transplant. These devices pose novel challenges for organ allocation, safety, training, and finances. This white paper describes the American Society of Transplant Surgeons' belief that organ preservation technology is a vital advance, but its use should not change fundamental aspects of organ allocation. Additional data elements need to be collected, made available for organ assessment by transplant professionals to allow determination of organ suitability in the case of reallocation and incorporated into risk adjustment methodology. Finally, further work is needed to determine the optimal strategy for management and oversight of perfused organs prior to transplantation.
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Affiliation(s)
| | | | - Shimul Shah
- University of Cincinnati, Cincinnati, OH, USA
| | - Mary Killackey
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Alan Reed
- University of Iowa, Iowa City, IA, USA
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Normothermic Ex Vivo Heart Perfusion: Effects of Live Animal Blood and Plasma Cross Circulation. ASAIO J 2018; 63:766-773. [PMID: 28394815 DOI: 10.1097/mat.0000000000000583] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Prolonged normothermic ex vivo heart perfusion could transform cardiac transplantation. To help identify perfusate components that might enable long-term perfusion, we evaluated the effects of cross-circulated whole blood and cross-circulated plasma from a live paracorporeal animal on donor porcine hearts preserved via normothermic ex vivo heart perfusion. Standard perfusion (SP; n = 40) utilized red blood cell/plasma perfusate and Langendorff technique for a goal of 12 hours. Cross-circulation groups used a similar circuit with the addition of cross-circulated venous whole blood (XC-blood; n = 6) or cross-circulated filtered plasma (XC-plasma; n = 7) between a live paracorporeal pig under anesthesia and the perfusate reservoir. Data included oxygen metabolism, vascular resistance, lactate production, left ventricular function, myocardial electrical impedance, and histopathologic injury score. All cross-circulation hearts were successfully perfused for 12 hours, compared with 22 of 40 SP hearts (55%; p = 0.002). Both cross-circulation groups demonstrated higher oxygen consumption and vascular resistance than standard hearts from hours 3-12. No significant differences were seen between XC-blood and XC-plasma hearts in any variable, including left ventricular dP/dT after 12 hours (1478 ± 700 mm Hg/s vs. 872 ± 500; p = 0.17). We conclude that cross circulation of whole blood or plasma from a live animal improves preservation of function of perfused hearts, and cross-circulated plasma performs similarly to cross-circulated whole blood.
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27
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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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28
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Abstract
BACKGROUND In recent years research which conforms to evidence-based medicine (EBM) has been required even in surgery. Prospective, randomized studies are carried out in order to provide justification for the benefits of new procedures. OBJECTIVE The acquisition of special features in surgery with respect to the application of EBM. MATERIAL AND METHODS The investigation period selected was from1933 to 2013; therefore, all disciplines within the German Society of Surgery were questioned on the achievement of revolutionary innovations. The investigation was carried out utilizing personal interviews and a questionnaire. Only novel methods which were developed in Germany were considered. The survey was completed by carrying out research in database files. RESULTS During the past 80 years 15 pioneering innovations have been published in surgical research, although the prerequisites of EBM were only partly met. They appear to be based on the lowest level of evidence as these methods were mostly published as case reports or case series in journals with a low impact factor. DISCUSSION In general, innovative surgical procedures through top level research are still being published in the form of case reports or case series. This allows a rapid distribution of research results to the surgical community. Controlled studies still do not represent an alternative for the introduction of pioneering surgical innovations.
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Affiliation(s)
- S Weber
- Klinik für Thorax-, Herz- und Gefäßchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - A Haverich
- Klinik für Thorax-, Herz- und Gefäßchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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Schraufnagel DP, Steffen RJ, Vargo PR, Attia T, Elgharably H, Hasan SM, Bribriesco A, Wierup P. Devices for ex vivo heart and lung perfusion. Expert Rev Med Devices 2018; 15:183-191. [PMID: 29376452 DOI: 10.1080/17434440.2018.1430568] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The number of organs available for heart and lung transplantation is far short of the number that is needed to meet demand. Perfusion and ventilation of donor organs after procurement has led to exciting advances in the field of cardiothoracic transplantation. The clinical implications of this technology allows for techniques to evaluate the quality of an organ, active rehabilitation of organs after procurement and prior to implantation, and increased time between organ procurement and implantation. This ex-vivo perfusion technique has also been referred to in the lay press as the 'heart in a box' or 'lung in a box.' AREAS COVERED This review includes information from case reports, case series, and clinical trials on ex vivo heart and lung perfusion. The focus is on the devices, ventilation and perfusion techniques, outcomes, and application of the technology. EXPERT COMMENTARY Ex vivo perfusion of donor hearts and lungs prior to transplantation has proven to be a viable alternative to standard cold-preservation strategies. Its use has allowed for ongoing expansion of the donor pool. The biggest barriers to expansion of this technology are access, cost, and lack of evidence which clearly supports superior outcomes.
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Affiliation(s)
- Dean P Schraufnagel
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Robert J Steffen
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Patrick R Vargo
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Tamer Attia
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Haytham Elgharably
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Saad M Hasan
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Alejandro Bribriesco
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Per Wierup
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
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Abstract
The growing disparity between the supply of donor hearts for transplantation and the demand for such organs has led to liberalization of the criteria for donor heart acceptance over the past few decades. The upper age limit and size restrictions for donor heart acceptance continue to be revised and hearts are being routinely used from donors with left ventricular dysfunction, left ventricular hypertrophy (LVH), cocaine use, multiple medical co-morbidities and after cardiopulmonary resuscitation. This article reviews recent data for use of such "expanded criteria" donor hearts and suggests ways to further increase the donor pool, including use of hearts from donors with hepatitis C and after circulatory determination of death. Donor biomarkers and risk scores may eventually aid in heart acceptance decisions, while ethical issues surrounding information sharing with transplant recipients remain a topic of great debate.
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Affiliation(s)
- Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
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31
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Abstract
Although total body perfusion with extracorporeal life support (ECLS) can be maintained for weeks, individual organ perfusion beyond 12 hours has yet to be achieved clinically. Normothermic ex situ heart perfusion (ESHP) offers the potential for prolonged cardiac preservation. We developed an ESHP system to study the effect of perfusate variables on organ preservation, with the ultimate goal of extending organ perfusion for ≥24 hours. Forty porcine hearts were perfused for a target of 12 hours. Hearts that maintained electromechanical activity and had a <3× increase in vascular resistance were considered successful preservations. Perfusion variables, metabolic byproducts, and histopathology were monitored and sampled to identify factors associated with preservation failure. Twenty-two of 40 hearts were successfully preserved at 12 hours. Successful 12 hour experiments demonstrated lower potassium (4.3 ± 0.8 vs. 5.0 ± 1.2 mmol/L; p = 0.018) and lactate (3.5 ± 2.8 vs. 4.5 ± 2.9 mmol/L; p = 0.139) levels, and histopathology revealed less tissue damage (p = 0.003) and less weight gain (p = 0.072). Results of these early experiments suggest prolonged ESHP is feasible, and that elevated lactate and potassium levels are associated with organ failure. Further studies are necessary to identify the ideal perfusate for normothermic ESHP.
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Li Y, Zeng Q, Liu G, Du J, Gao B, Wang W, Zheng Z, Hu S, Ji B. Development and Evaluation of Heartbeat: A Machine Perfusion Heart Preservation System. Artif Organs 2017; 41:E240-E250. [PMID: 28800676 DOI: 10.1111/aor.12867] [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: 03/30/2016] [Revised: 08/18/2016] [Accepted: 08/26/2016] [Indexed: 12/11/2022]
Abstract
Static cold storage is accompanied with a partial safe ischemic interval for donor hearts. In this current study, a machine perfusion system was built to provide a better preservation for the donor heart and assessment for myocardial function. Chinese mini-swine (weight 30-35 kg, n = 16) were randomly divided into HTK, Celsior, and Heartbeat groups. All donor hearts were respectively preserved for 8 hours under static cold storage or machine perfusion. The perfusion solution is aimed to maintain its homeostasis based on monitoring the Heartbeat group. The ultrastructure of myocardium suggests better myocardial protection in the Heartbeat group compared with HTK or Celsior-preserved hearts. The myocardial and coronary artery structural and functional integrity was evaluated by immunofluorescence and Western blots in the Heartbeat. In the Heartbeat group, donor hearts maintained a high adenosine triphosphate level. Bcl-2 and Beclin-1 protein demonstrates high expression in the Celsior group. The Heartbeat system can be used to preserve donor hearts, and it could guarantee the myocardial and endothelial function of hearts during machine perfusion. Translating Heartbeat into clinical practice, it is such as to impact on donor heart preservation for cardiac transplantation.
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Affiliation(s)
- Yongnan Li
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Qingdong Zeng
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Junzhe Du
- Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Wei Wang
- Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhe Zheng
- Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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34
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Fukushima N. Current status and future aspects of ex vivo allograft perfusion for heart transplantation. J Heart Lung Transplant 2017; 36:247-249. [DOI: 10.1016/j.healun.2017.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/21/2016] [Accepted: 01/04/2017] [Indexed: 11/28/2022] Open
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35
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Schmack B, Weymann A, Mohite P, Garcia Saez D, Zych B, Sabashnikov A, Zeriouh M, Schamroth J, Koch A, Soresi S, Ananiadou O, De Robertis F, Karck M, Simon AR, Popov AF. Contemporary review of the organ care system in lung transplantation: potential advantages of a portable ex-vivo lung perfusion system. Expert Rev Med Devices 2016; 13:1035-1041. [DOI: 10.1080/17434440.2016.1243464] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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36
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Abstract
Although the number of available donor hearts severely limits the epidemiologic impact of heart transplantation on patients with heart failure, patients with end-stage heart failure unresponsive to medical management currently have no other viable alternatives. Destination therapy with a ventricular assist device is the closest toward approaching clinical reality but has been plagued with problems of infection and stroke. The purpose of this review is to summarize recent developments in the field that may broaden the clinical impact of heart transplantation. For example, novel methods of cardiac preservation are being designed to safely evaluate and utilize “extended criteria” donors. Surgical techniques and medical management have reduced the incidence of postoperative right heart failure, and immunosuppressive regimens promise to limit chronic graft vascular disease.
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37
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38
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Cold Crystalloid Perfusion Provides Cardiac Preservation Superior to Cold Storage for Donation After Circulatory Death. Transplantation 2016; 100:546-53. [DOI: 10.1097/tp.0000000000000926] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fichter AM, Ritschl LM, Borgmann A, Humbs M, Luppa PB, Wolff KD, Mücke T. Development of an Extracorporeal Perfusion Device for Small Animal Free Flaps. PLoS One 2016; 11:e0147755. [PMID: 26808996 PMCID: PMC4726627 DOI: 10.1371/journal.pone.0147755] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 01/07/2016] [Indexed: 11/19/2022] Open
Abstract
Background Extracorporeal perfusion (ECP) might prolong the vital storage capabilities of composite free flaps, potentially opening a wide range of clinical applications. Aim of the study was the development a validated low-cost extracorporeal perfusion model for further research in small animal free flaps. Methods After establishing optimal perfusion settings, a specially designed extracorporeal perfusion system was evaluated during 8-hour perfusion of rat epigastric flaps followed by microvascular free flap transfer. Controls comprised sham-operation, ischemia and in vivo perfusion. Flaps and perfusate (diluted blood) were closely monitored by blood gas analysis, combined laser Doppler flowmetry and remission spectroscopy and Indocyanine-Green angiography. Evaluations were complemented by assessment of necrotic area and light microscopy at day 7. Results ECP was established and maintained for 8 hours with constant potassium and pH levels. Subsequent flap transfer was successful. Notably, the rate of necrosis of extracorporeally perfused flaps (27%) was even lower than after in vivo perfusion (49%), although not statistically significant (P = 0,083). After sham-operation, only 6% of the total flap area became necrotic, while 8-hour ischemia led to total flap loss (98%). Angiographic and histological findings confirmed these observations. Conclusions Vital storage capabilities of microvascular flaps can be prolonged by temporary ECP. Our study provides important insights on the pathophysiological processes during extracorporeal tissue perfusion and provides a validated small animal perfusion model for further studies.
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Affiliation(s)
- Andreas M. Fichter
- Department of Oral and Maxillo-Facial Surgery, Technische Universität München, Klinikum Rechts der Isar, München, Germany
- * E-mail:
| | - Lucas M. Ritschl
- Department of Oral and Maxillo-Facial Surgery, Technische Universität München, Klinikum Rechts der Isar, München, Germany
| | - Anna Borgmann
- Department of Oral and Maxillo-Facial Surgery, Technische Universität München, Klinikum Rechts der Isar, München, Germany
| | - Martin Humbs
- Department of Oral and Maxillo-Facial Surgery, Technische Universität München, Klinikum Rechts der Isar, München, Germany
| | - Peter B. Luppa
- Institute for Clinical Chemistry and Pathobiochemistry, Technische Universität München, Klinikum Rechts der Isar, München, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillo-Facial Surgery, Technische Universität München, Klinikum Rechts der Isar, München, Germany
| | - Thomas Mücke
- Department of Oral and Maxillo-Facial Surgery, Technische Universität München, Klinikum Rechts der Isar, München, Germany
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40
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White CW, Ambrose E, Müller A, Li Y, Le H, Hiebert B, Arora R, Lee TW, Dixon I, Tian G, Nagendran J, Hryshko L, Freed D. Assessment of donor heart viability during ex vivo heart perfusion. Can J Physiol Pharmacol 2015; 93:893-901. [DOI: 10.1139/cjpp-2014-0474] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Ex vivo heart perfusion (EVHP) may facilitate resuscitation of discarded donor hearts and expand the donor pool; however, a reliable means of demonstrating organ viability prior to transplantation is required. Therefore, we sought to identify metabolic and functional parameters that predict myocardial performance during EVHP. To evaluate the parameters over a broad spectrum of organ function, we obtained hearts from 9 normal pigs and 37 donation after circulatory death pigs and perfused them ex vivo. Functional parameters obtained from a left ventricular conductance catheter, oxygen consumption, coronary vascular resistance, and lactate concentration were measured, and linear regression analyses were performed to identify which parameters best correlated with myocardial performance (cardiac index: mL·min–1·g–1). Functional parameters exhibited excellent correlation with myocardial performance and demonstrated high sensitivity and specificity for identifying hearts at risk of poor post-transplant function (ejection fraction: R2 = 0.80, sensitivity = 1.00, specificity = 0.85; stroke work: R2 = 0.76, sensitivity = 1.00, specificity = 0.77; minimum dP/dt: R2 = 0.74, sensitivity = 1.00, specificity = 0.54; tau: R2 = 0.51, sensitivity = 1.00, specificity = 0.92), whereas metabolic parameters were limited in their ability to predict myocardial performance (oxygen consumption: R2 = 0.28; coronary vascular resistance: R2 = 0.20; lactate concentration: R2 = 0.02). We concluded that evaluation of functional parameters provides the best assessment of myocardial performance during EVHP, which highlights the need for an EVHP device capable of assessing the donor heart in a physiologic working mode.
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Affiliation(s)
- Christopher W. White
- Cardiac Surgery, St. Boniface Hospital, University of Manitoba, 409 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Emma Ambrose
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Alison Müller
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Yun Li
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Hoa Le
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Brett Hiebert
- Cardiac Surgery, St. Boniface Hospital, University of Manitoba, 409 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Rakesh Arora
- Cardiac Surgery, St. Boniface Hospital, University of Manitoba, 409 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
- National Research Council Institute for Biodiagnostics, 435 Ellice Avenue, Winnipeg, MB R3B 1Y6, Canada
| | - Trevor W. Lee
- Anesthesia and Perioperative Medicine, St. Boniface Hospital, University of Manitoba, 409 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Ian Dixon
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Ganghong Tian
- National Research Council Institute for Biodiagnostics, 435 Ellice Avenue, Winnipeg, MB R3B 1Y6, Canada
| | - Jayan Nagendran
- Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 2D4.34 WMC, 8440-112 Street, Edmonton, AB T6G 2B7, Canada
| | - Larry Hryshko
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Darren Freed
- Cardiac Surgery, St. Boniface Hospital, University of Manitoba, 409 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
- National Research Council Institute for Biodiagnostics, 435 Ellice Avenue, Winnipeg, MB R3B 1Y6, Canada
- Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 2D4.34 WMC, 8440-112 Street, Edmonton, AB T6G 2B7, Canada
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Ardehali A, Esmailian F, Deng M, Soltesz E, Hsich E, Naka Y, Mancini D, Camacho M, Zucker M, Leprince P, Padera R, Kobashigawa J. Ex-vivo perfusion of donor hearts for human heart transplantation (PROCEED II): a prospective, open-label, multicentre, randomised non-inferiority trial. Lancet 2015; 385:2577-84. [PMID: 25888086 DOI: 10.1016/s0140-6736(15)60261-6] [Citation(s) in RCA: 323] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The Organ Care System is the only clinical platform for ex-vivo perfusion of human donor hearts. The system preserves the donor heart in a warm beating state during transport from the donor hospital to the recipient hospital. We aimed to assess the clinical outcomes of the Organ Care System compared with standard cold storage of human donor hearts for transplantation. METHODS We did this prospective, open-label, multicentre, randomised non-inferiority trial at ten heart-transplant centres in the USA and Europe. Eligible heart-transplant candidates (aged >18 years) were randomly assigned (1:1) to receive donor hearts preserved with either the Organ Care System or standard cold storage. Participants, investigators, and medical staff were not masked to group assignment. The primary endpoint was 30 day patient and graft survival, with a 10% non-inferiority margin. We did analyses in the intention-to-treat, as-treated, and per-protocol populations. This trial is registered with ClinicalTrials.gov, number NCT00855712. FINDINGS Between June 29, 2010, and Sept 16, 2013, we randomly assigned 130 patients to the Organ Care System group (n=67) or the standard cold storage group (n=63). 30 day patient and graft survival rates were 94% (n=63) in the Organ Care System group and 97% (n=61) in the standard cold storage group (difference 2·8%, one-sided 95% upper confidence bound 8·8; p=0·45). Eight (13%) patients in the Organ Care System group and nine (14%) patients in the standard cold storage group had cardiac-related serious adverse events. INTERPRETATION Heart transplantation using donor hearts adequately preserved with the Organ Care System or with standard cold storage yield similar short-term clinical outcomes. The metabolic assessment capability of the Organ Care System needs further study. FUNDING TransMedics.
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Affiliation(s)
| | | | - Mario Deng
- UCLA Medical Center, Los Angeles, CA, USA
| | | | | | | | - Donna Mancini
- Columbia University Medical Center, New York, NY, USA
| | - Margarita Camacho
- St Barnabas Heart Center, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Mark Zucker
- St Barnabas Heart Center, Newark Beth Israel Medical Center, Newark, NJ, USA
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White CW, Hasanally D, Mundt P, Li Y, Xiang B, Klein J, Müller A, Ambrose E, Ravandi A, Arora RC, Lee TW, Hryshko LV, Large S, Tian G, Freed DH. A whole blood–based perfusate provides superior preservation of myocardial function during ex vivo heart perfusion. J Heart Lung Transplant 2015; 34:113-121. [DOI: 10.1016/j.healun.2014.09.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 09/04/2014] [Accepted: 09/19/2014] [Indexed: 11/29/2022] Open
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Donor evaluation in heart transplantation: The end of the beginning. J Heart Lung Transplant 2014; 33:1105-13. [DOI: 10.1016/j.healun.2014.05.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 05/16/2014] [Accepted: 05/28/2014] [Indexed: 12/20/2022] Open
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Michel SG, La Muraglia GM, Madariaga MLL, Titus JS, Selig MK, Farkash EA, Allan JS, Anderson LM, Madsen JC. Preservation of donor hearts using hypothermic oxygenated perfusion. Ann Transplant 2014; 19:409-16. [PMID: 25139381 DOI: 10.12659/aot.890797] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Hypothermic machine perfusion of donor hearts enables continuous aerobic metabolism and washout of toxic metabolic byproducts. We evaluated the effect of machine perfusion on cardiac myocyte integrity in hearts preserved for 4 h in a novel device that provides pulsatile oxygenated hypothermic perfusion (Paragonix Sherpa Perfusion™ Cardiac Transport System). MATERIAL AND METHODS Pig hearts were harvested and stored in Celsior® solution for 4 h using either conventional cold storage on ice (4-h CS, n=6) or the Sherpa device (4-h pulsatile perfusion (PP), n=6). After cold preservation, hearts were evaluated using a non-working heart Langendorff system. Controls (n=3) were reperfused immediately after organ harvest. Biopsies were taken from the apex of the left ventricle before storage, after storage, and after reperfusion to measure ATP content and endothelin-1 in the tissue. Ultrastructural analysis using electron microscopy was performed. RESULTS Four-hour CS, 4-h PP, and control group did not show any significant differences in systolic or diastolic function (+dP/dt, -dP/dt, EDP). Four-hour PP hearts showed significantly more weight gain than 4-h CS after preservation, which shows that machine perfusion led to myocardial edema. Four-hour CS led to higher endothelin-1 levels after preservation, suggesting more endothelial dysfunction compared to 4-h PP. Electron microscopy revealed endothelial cell rupture and damaged muscle fibers in the 4-h CS group after reperfusion, but the cell structures were preserved in the 4-h PP group. CONCLUSIONS Hypothermic pulsatile perfusion of donor hearts leads to a better-preserved cell structure compared to the conventional cold storage method. This may lead to less risk of primary graft failure after orthotopic heart transplantation.
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Affiliation(s)
- Sebastian G Michel
- Department of Surgery, Transplantation Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Glenn M La Muraglia
- Department of Surgery, Transplantation Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Maria Lucia L Madariaga
- Department of Surgery, Transplantation Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - James S Titus
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston, USA
| | - Martin K Selig
- Department of Pathology, Massachusetts General Hospital, Boston, USA
| | - Evan A Farkash
- Department of Pathology, Massachusetts General Hospital, Boston, USA
| | - James S Allan
- Department of Surgery, Transplantation Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | | | - Joren C Madsen
- Department of Surgery, Transplantation Biology Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, USA
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Messer S, Ardehali A, Tsui S. Normothermic donor heart perfusion: current clinical experience and the future. Transpl Int 2014; 28:634-42. [PMID: 24853906 DOI: 10.1111/tri.12361] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 03/05/2014] [Accepted: 05/19/2014] [Indexed: 11/28/2022]
Abstract
Following the first successful heart transplant in 1967, more than 100,000 heart transplants have been carried out worldwide. These procedures have mostly relied on cold ischaemic preservation of the donor heart because this simple technique is inexpensive and relatively reliable. However, the well-known limitations of cold ischaemic preservation imposes significant logistical challenges to heart transplantation which put a ceiling on the immediate success on this life-saving therapy, and limits the number of donor hearts that can be safely transplanted annually. Although the theoretical advantages of normothermic donor heart perfusion have been recognised for over a century, the technology to transport donor hearts in this state has only been developed within the last decade. The Organ Care System (OCS) which is designed and manufactured by TransMedics Inc. is currently the only commercially available device with this capability. This article reviews the history of normothermic heart perfusion and the clinical experience with the TransMedics OCS to date. We have also attempted to speculate on the future possibilities of this innovative and exciting technology.
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Affiliation(s)
- Simon Messer
- Transplant Unit, Papworth Hospital, Cambridgeshire, UK
| | - Abbas Ardehali
- Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Steven Tsui
- Transplant Unit, Papworth Hospital, Cambridgeshire, UK
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Koerner MM, Ghodsizad A, Schulz U, El Banayosy A, Koerfer R, Tenderich G. Normothermic Ex Vivo Allograft Blood Perfusion in Clinical Heart Transplantation. Heart Surg Forum 2014; 17:E141-5. [DOI: 10.1532/hsf98.2014332] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
<p><b>Background:</b> Cold ischemia associated with cold static storage is an independent risk factor for primary allograft failure and survival of patients after orthotopic heart transplantation. The effects of normothermic ex vivo allograft blood perfusion on outcomes after orthotopic heart transplantation compared to cold static storage have been studied.</p><p><b>Methods:</b> In this prospective, nonrandomized, single-institutional clinical study, normothermic ex vivo allograft blood perfusion has been performed using an organ care system (OCS) (TransMedics, Andover, MA, USA). Included were consecutive adult transplantation patients who received an orthotopic heart transplantation (oHTx) without a history of any organ transplantation, in the absence of a congenital heart disorder as an underlying disease and not being in need of a combined heart-lung transplantation. Furthermore, patients with fixed pulmonary hypertension, ventilator dependency, chronic renal failure, or panel reactive antibodies >20% and positive T-cell cross-matching were excluded. Inclusion criteria for donor hearts was age of <55 years, systolic blood pressure >85 mmHg at the time of final heart assessment under moderate inotropic support, heart rate of <120 bpm at the time of explantation, and left ventricular ejection fraction >40% assessed by an transcutaneous echo/Doppler study with the absence of gross wall motion abnormalities, absence of left ventricular hypertrophy, and absence of valve abnormalities. Donor hearts which were conventionally cold stored with histidine-tryptophan-ketoglutarate solution (Custodiol; Koehler Chemie, Ansbach, Germany) constituted the control group. The primary end point was the recipients' survival at 30 days and 1 and 2 years after their heart transplantation. Secondary end points were primary and chronic allograft failure, noncardiac complications, and length of hospital stay.</p><p><b>Results:</b> Over a 2-year period (January 2006 to July 2008), 159 adult cardiac allografts were transplanted. Twenty-nine were assigned for normothermic ex vivo allograft blood perfusion and 130 for cold static storage with HTK solution. Cumulative survival rates at 30 days and 1 and 2 years were 96%, 89%, and 89%, respectively, whereas in the cold static storage group survival after oHTx was 95%, 81%, and 79%. Primary graft failure was less frequent in the recipients of an oHTx who received a donor heart which had been preserved with normothermic ex vivo allograft blood perfusion using an OCS (6.89% versus 15.3%; <i>P</i> = .20). Episodes of severe acute rejection (23% versus 17.2%; <i>P</i> = .73), as well as, cases of acute renal failure requiring haemodialysis (25.3% versus 10%; <i>P</i> = .05) were more frequent diagnosed among recipients of a donor heart which had been preserved using the cold static storage. The length of hospital stay did not differ (26 days versus 28 days; <i>P</i> = .80) in both groups.</p><p><b>Conclusions:</b> Normothermic ex vivo allograft blood perfusion in adult clinical orthotopic heart transplantation contributes to better outcomes after transplantation in regard to recipient survival, incidence of primary graft dysfunction, and incidence of acute rejection.</p>
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Izamis ML, Efstathiades A, Keravnou C, Georgiadou S, Martins PN, Averkiou MA. Effects of air embolism size and location on porcine hepatic microcirculation in machine perfusion. Liver Transpl 2014; 20:601-11. [PMID: 24478135 DOI: 10.1002/lt.23838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 01/05/2014] [Indexed: 02/07/2023]
Abstract
The handling of donor organs frequently introduces air into the microvasculature, but little is known about the extent of the damage caused as a function of the embolism size and distribution. Here we introduced embolisms of different sizes into the portal vein, the hepatic artery, or both during the flushing stage of porcine liver procurement. The outcomes were evaluated during 3 hours of machine perfusion and were compared to the outcomes of livers with no embolisms. Dynamic contrast-enhanced ultrasound (DCEUS) was used to assess the perfusion quality, and it demonstrated that embolisms tended to flow mostly into the left lobe, occasionally into the right lobe, and rarely into the caudate lobe. Major embolisms could disrupt the flow entirely, whereas minor embolisms resulted in reduced or heterogeneous flow. Embolisms occasionally migrated to different regions of the same lobe and, regardless of their size, caused a general deterioration in the flow over time. Histological damage resulted primarily when both vessels of the liver were compromised, whereas bile production was diminished in livers that had arterial embolisms. Air embolisms produced a dose-dependent increase in vascular resistance and a decline in oxygen consumption. This is the first article to quantify the impact of air embolisms on microcirculation in an experimental model, and it demonstrates that air embolisms have the capacity to degrade the integrity of donor organs. The extent of organ damage is strongly dependent on the size and distribution of air embolisms. The diagnosis of embolism severity can be safely and easily made with DCEUS.
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Affiliation(s)
- Maria-Louisa Izamis
- Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia, Cyprus
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Raemdonck D, Neyrinck A, Cypel M, Keshavjee S. Ex‐vivo lung perfusion. Transpl Int 2014; 28:643-56. [DOI: 10.1111/tri.12317] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 03/11/2014] [Indexed: 01/12/2023]
Affiliation(s)
- Dirk Raemdonck
- Department of Thoracic Surgery University Hospitals Leuven Leuven Belgium
- Laboratory for Experimental Thoracic Surgery KU Leuven University Leuven Belgium
| | - Arne Neyrinck
- Laboratory for Experimental Thoracic Surgery KU Leuven University Leuven Belgium
- Department of Anaesthesiology University Hospitals Leuven Leuven Belgium
| | - Marcelo Cypel
- Division of Thoracic Surgery Toronto General Hospital Toronto ON Canada
- The Latner Thoracic Surgery Laboratories Toronto General Research Institute Toronto ON Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery Toronto General Hospital Toronto ON Canada
- The Latner Thoracic Surgery Laboratories Toronto General Research Institute Toronto ON Canada
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Tolboom H, Makhro A, Rosser BA, Wilhelm MJ, Bogdanova A, Falk V. Recovery of donor hearts after circulatory death with normothermic extracorporeal machine perfusion. Eur J Cardiothorac Surg 2014; 47:173-9; discussion 179. [PMID: 24727935 DOI: 10.1093/ejcts/ezu117] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES A severe donor organ shortage leads to the death of a substantial number of patients who are listed for transplantation. The use of hearts from donors after circulatory death could significantly expand the donor organ pool, but due to concerns about their viability, these are currently not used for transplantation. We propose short-term ex vivo normothermic machine perfusion (MP) to improve the viability of these ischaemic donor hearts. METHODS Hearts from male Lewis rats were subjected to 25 min of global in situ warm ischaemia (WI) (37°C), explanted, reconditioned for 60 min with normothermic (37°C) MP with diluted autologous blood and then stored for 4 h at 0-4°C in Custodiol cold preservation solution. Fresh and ischaemic hearts stored for 4 h in Custodiol were used as controls. Graft function was assessed in a blood-perfused Langendorff circuit. RESULTS During reconditioning, both the electrical activity and contractility of the ischaemic hearts recovered rapidly. Throughout the Langendorff reperfusion, the reconditioned ischaemic hearts had a higher average heart rate and better contractility compared with untreated ischaemic controls. Moreover, the reconditioned ischaemic hearts had higher tissue adenosine triphosphate levels and a trend towards improved tissue redox state. Perfusate levels of troponin T, creatine kinase and lactate dehydrogenase were not significantly lower than those of untreated ischaemic controls. The micro- and macroscopic appearance of the reconditioned ischaemic hearts were improved compared with ischaemic controls, but in both groups myocardial damage and oedema were evident. CONCLUSIONS Our results indicate that functional recovery from global WI is possible during short-term ex vivo reperfusion, allowing subsequent cold storage without compromising organ viability. We expect that once refined and validated, this approach may enable safe transplantation of hearts obtained from donation after circulatory death.
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Affiliation(s)
- Herman Tolboom
- Division of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Asya Makhro
- Institute of Veterinary Physiology, Vetsuisse Faculty and the Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Zürich, Switzerland
| | - Barbara A Rosser
- Department of Visceral and Transplant Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Markus J Wilhelm
- Division of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Anna Bogdanova
- Institute of Veterinary Physiology, Vetsuisse Faculty and the Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Zürich, Switzerland
| | - Volkmar Falk
- Division of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
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Yang Y, Lin H, Wen Z, Huang A, Huang G, Hu Y, Zhong Y, Li B. Keeping donor hearts in completely beating status with normothermic blood perfusion for transplants. Ann Thorac Surg 2013; 95:2028-34. [PMID: 23635448 DOI: 10.1016/j.athoracsur.2013.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 03/07/2013] [Accepted: 03/07/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Previously, we reported the preservation method of donor hearts in an empty beating status with mild hypothermic perfusion. To completely avoid cardiac arrest and myocardial ischemia, we performed the beating preservation technique from procurement of hearts to transplants and assessed its efficacy for long-term preservation and feasibility for heart transplantation. METHODS Thirty-two swine donor hearts were preserved in beating status (group A, n = 8 pairs, perfused continuously with normothermic blood) or in static cold storage (group B, n = 8 pairs, stored in 4°C histidine-tryptophan-ketoglutarate solutions) for 8 hours. Then the donor hearts were implanted either in beating or static status. During transplantation, the incidence of arrhythmia, duration of anastomosis and cardiopulmonary bypass, and dosage of inotropic drugs were recorded. Hemodynamics of left ventricle and serum level of creatine kinase-MB were measured during transplantation. Myocardial ultrastructure was observed. RESULTS Compared with group B, in group A the anastomotic time was significantly longer, the cardiopulmonary bypass time was significantly shorter, the cardiac output was larger, and the incidence of arrhythmia, dosage of cardiovascular-active drugs, and serum level of creatine kinase-MB were lower. After declamping for 2 hours and 3.5 hours, the left ventricular hemodynamics of group A was significantly better than that of group B. The myocardial ultrastructure of group A was superior to that of group B. CONCLUSIONS Preservation of donor hearts in beating status with continuous, normothermic, blood perfusion is an effective approach for long-term preservation and is appropriate for heart transplantation.
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Affiliation(s)
- Yong Yang
- Department of Cardiothoracic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
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