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Experimental Models of Ischemic Lung Damage for the Study of Therapeutic Reconditioning During Ex Vivo Lung Perfusion. Transplant Direct 2022; 8:e1337. [PMID: 35702630 PMCID: PMC9191352 DOI: 10.1097/txd.0000000000001337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022] Open
Abstract
Background. Ex vivo lung perfusion (EVLP) may allow therapeutic reconditioning of damaged lung grafts before transplantation. This study aimed to develop relevant rat models of lung damage to study EVLP therapeutic reconditioning for possible translational applications. Methods. Lungs from 31 rats were exposed to cold ischemia (CI) or warm ischemia (WI), inflated at various oxygen fractions (FiO2), followed by 3 h EVLP. Five groups were studied as follow: (1) C21 (control): 3 h CI (FiO2 0.21); (2) C50: 3 h CI (FiO2 0.5); (3) W21: 1 h WI, followed by 2 h CI (FiO2 0.21); (4) W50: 1 h WI, followed by 2 h CI (FiO2 0.5); and (5) W2h: 2 h WI, followed by 1 h CI (FiO2 0.21). Following 3 h EVLP, we measured static pulmonary compliance (SPC), pulmonary vascular resistance, lung weight gain (edema), oxygenation capacity (differential partial pressure of oxygen), and protein carbonyls in lung tissue (oxidative stress), as well as lactate dehydrogenase (LDH, lung injury), nitrotyrosine (nitro-oxidative stress), interleukin-6 (IL-6, inflammation), and proteins (permeability edema) in bronchoalveolar lavage (BAL). Perivascular edema was quantified by histology. Results. No significant alterations were noted in C21 and C50 groups. W21 and W50 groups had reduced SPC and disclosed increased weight gain, BAL proteins, nitrotyrosine, and LDH. These changes were more severe in the W50 group, which also displayed greater oxidative stress. In contrast, both W21 and W50 showed comparable perivascular edema and BAL IL-6. In comparison with the other WI groups, W2h showed major weight gain, perivascular edema, SPC reduction, drop of differential partial pressure of oxygen, and massive increases of BAL LDH and proteins but comparable increase of IL-6 and biomarkers of oxidative stress. Conclusions. These models of lung damage of increasing severity might be helpful to evaluate new strategies for EVLP therapeutic reconditioning. A model combining 1 h WI and inflation at FiO2 of 0.5 seems best suited for this purpose by reproducing major alterations of clinical lung ischemia-reperfusion injury.
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Palleschi A, Rosso L, Ruggeri GM, Croci GA, Rossetti V, Citerio G, Grasselli G, Nosotti M, Zanella A. Overcoming the Limits of Reconditioning: Seventeen Hours of EVLP With Successful Transplantation From Uncontrolled Circulatory Death Donor. Transplantation 2021; 105:2620-2624. [PMID: 33496562 PMCID: PMC8612888 DOI: 10.1097/tp.0000000000003646] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/17/2020] [Accepted: 12/20/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uncontrolled donation after circulatory death (DCD) donors are an extraordinary resource to increase the number of lungs available for transplantation. However, the risk of the warm ischemia resulting from cardiac arrest to irreversibly damage the organs is considerable. Moreover, graft preservation issues and organizational problems often worsen the dangerous effects of warm ischemia. Ex vivo lung perfusion (EVLP) enables us to evaluate and recondition lungs whose functionality is doubtful, as well as to overcome the difficulties related to time and logistics. METHODS We report the case of uncontrolled DCD lungs successfully treated with an exceptionally prolonged EVLP. Because the donor's blood count and liver biopsy showed signs of possible leukemia, EVLP was protracted up to 17 h while waiting for immunohistochemical analyses to rule out this diagnosis; eventually, the results came back negative, and the lungs were judged suitable for transplantation. RESULTS The recipient was a 32-y-old male individual with cystic fibrosis, colonized by Pandoraea pnomenusa. Bilateral transplantation required central extracorporeal membrane oxygenation. The patient was extubated after 36 h and was discharged 21 d after the operation. Despite early recolonization by Pandoraea pnomenusa and airway complications requiring pneumatic dilatation, he is alive and has a satisfactory respiratory function 15 mo after transplantation. CONCLUSIONS Uncontrolled DCD represents a challenge due to both logistical issues and the complexity of graft evaluation before procurement. EVLP with cellular perfusate could be a valuable tool to overcome these limits. Nonetheless, caution should be exercised when interpreting the effects of this technique on airway healing.
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Affiliation(s)
- Alessandro Palleschi
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lorenzo Rosso
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giulia Maria Ruggeri
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Alberto Croci
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Pathology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Rossetti
- Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- San Gerardo Hospital, ASST-Monza, Monza, Italy
- University of Milano-Bicocca, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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3
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Hirano Y, Sugimoto S, Yamamoto S, Okada M, Otani S, Ohara T, Yamane M, Matsukawa A, Oto T, Toyooka S. Prolonged warm ischemia exacerbated acute rejection after lung transplantation from donation after cardiac death in a mouse. Gen Thorac Cardiovasc Surg 2019; 68:57-62. [PMID: 31367969 DOI: 10.1007/s11748-019-01181-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/07/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In lung transplantation (LTx) from donation after cardiac death (DCD), the donor lungs are inevitably exposed to warm ischemic time (WIT) between the cardiac arrest and the initiation of cold preservation. We conducted this study to examine the effect of prolonged WIT on lung allograft rejection in a murine model of LTx from DCD. METHODS Allogeneic BALB/c → B6 LTx from DCD was performed with a WIT of 15 min (WIT15 group, n = 5) or 60 min (WIT60 group, n = 5). Recipients were immunosuppressed by perioperative costimulatory blockade. The lung allografts were analyzed by histology and flow cytometry on day 7 after the LTx. RESULTS Histologically, the rejection grade in the WIT60 group was significantly higher than that in the WIT15 group (3.4 ± 0.4 vs. 2.2 ± 0.2, P = 0.0278). Moreover, the intragraft CD8+ to CD4+ T cell ratio in the WIT60 group was significantly higher than that in the WIT15 group (2.3 ± 0.12 vs. 1.2 ± 0.11, P < 0.0001). CONCLUSIONS Prolonged WIT could exacerbate the severity of lung allograft rejection after LTx from DCD. Minimization of the WIT could improve the outcomes after LTx from DCD.
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Affiliation(s)
- Yutaka Hirano
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Seiichiro Sugimoto
- Department of General Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Sumiharu Yamamoto
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masanori Okada
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shinji Otani
- Department of Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Toshiaki Ohara
- Department of Pathology and Experimental Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masaomi Yamane
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akihiro Matsukawa
- Department of Pathology and Experimental Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takahiro Oto
- Department of Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Shinichi Toyooka
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Mehra MR, Jarcho JA, Cherikh W, Vaduganathan M, Lehman RR, Smits J, Stehlik J. The Drug-Intoxication Epidemic and Solid-Organ Transplantation. N Engl J Med 2018; 378:1943-1945. [PMID: 29768141 DOI: 10.1056/nejmc1802706] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | | | | | | | | | - Jacqueline Smits
- Eurotransplant International Foundation, Leiden, the Netherlands
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5
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The impact of alteplase on pulmonary graft function in donation after circulatory death - An experimental study. Ann Med Surg (Lond) 2017; 22:1-6. [PMID: 28839932 PMCID: PMC5560118 DOI: 10.1016/j.amsu.2017.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 08/07/2017] [Accepted: 08/07/2017] [Indexed: 11/28/2022] Open
Abstract
Objective Lung transplantation is hampered by the lack of organs resulting in deaths on the waiting list. The usage of donation after circulatory death (DCD) lungs would dramatically increase donor availability. The most optimal organ preservation method, and the need for antithrombotic and fibrinolytic treatment to prevent thrombosis in the donor lungs is currently on debate. The present study investigated, in a simulated clinical DCD situation, whether the addition of alteplase in the flush-perfusion solution at the time of pulmonary graft harvesting could prevent thrombosis in the donor lung and thereby improve pulmonary graft function. Methods Twelve Swedish domestic pigs were randomized into two groups. All animals underwent ventricular fibrillation and were then left untouched for 1 h after declaration of death. None of the animals received heparin. The lungs were then harvested and flush-perfused with Perfadex® solution and the organs were then stored at 8 °C for 4 h. In one group alteplase was added to the Perfadex® solution (donation after cardiac death with alteplase (DCD-A)) and in the other, it was not (DCD). Lung function was evaluated, using ex vivo lung perfusion (EVLP), with blood gases at different oxygen levels, pulmonary vascular resistance (PVR), lung weight, and macroscopic appearance. Results During EVLP, there were no significant differences between groups in PaO2 at any investigated FiO2 level (1.0, 0.5, or 0.21). At FiO2 1.0, the PaO2 in the DCD and DCD-A was 51.7 ± 2.05 kPa and 60.3 ± 3.67 kPa, respectively (p = 0.1320). There were no significant differences between groups PVR levels, in the DCD (372 ± 31 dyne x s/cm5) and in the DCD-A (297 ± 37 dyne x s/cm5) groups (p = 0.1720). There was no significant difference between groups in macroscopic appearance. Conclusions All the lungs showed excellent blood gases after EVLP, and they all meet the criteria's for clinical lung transplantation. The use of alteplase did not seem to have any obvious benefit to the donor lungs in a DCD situation. The donor lungs treated with alteplas showed slightly better blood gases and slightly lower PVR compared to the group without alteplas, however the difference was not significant. DCD appears to be a safe and effective method to expand the donor pool.
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Valenza F, Citerio G, Palleschi A, Vargiolu A, Fakhr BS, Confalonieri A, Nosotti M, Gatti S, Ravasi S, Vesconi S, Pesenti A, Blasi F, Santambrogio L, Gattinoni L. Successful Transplantation of Lungs From an Uncontrolled Donor After Circulatory Death Preserved In Situ by Alveolar Recruitment Maneuvers and Assessed by Ex Vivo Lung Perfusion. Am J Transplant 2016; 16:1312-8. [PMID: 26603283 PMCID: PMC5021126 DOI: 10.1111/ajt.13612] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/16/2015] [Accepted: 10/14/2015] [Indexed: 01/25/2023]
Abstract
We developed a protocol to procure lungs from uncontrolled donors after circulatory determination of death (NCT02061462). Subjects with cardiovascular collapse, treated on scene by a resuscitation team and transferred to the emergency room, are considered potential donors once declared dead. Exclusion criteria include unwitnessed collapse, no-flow period of >15 min and low flow >60 min. After death, lung preservation with recruitment maneuvers, continuous positive airway pressure, and protective mechanical ventilation is applied to the donor. After procurement, ex vivo lung perfusion (EVLP) is performed. From November 2014, 10 subjects were considered potential donors; one of these underwent the full process of procurement, EVLP, and transplantation. The donor was a 46-year-old male who died because of thoracic aortic dissection. Lungs were procured 4 h and 48 min after death, and deemed suitable for transplantation after EVLP. Lungs were then offered to a rapidly deteriorating recipient with cystic fibrosis (lung allocation score [LAS] 46) who consented to the transplant in this experimental setting. Six months after transplantation, the recipient is in good condition (forced expiratory volume in 1 s 85%) with no signs of rejection. This protocol allowed procurement of lungs from an uncontrolled donor after circulatory determination of death following an extended period of warm ischemia.
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Affiliation(s)
- F. Valenza
- Dipartimento di Anestesia Rianimazione (Intensiva e Sub intensiva) e Terapia del doloreFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly,Dipartimento di Fisiopatologica Medico‐Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly
| | - G. Citerio
- Scuola di Medicina e ChirurgiaUniversità di Milano‐BicoccaMilanItaly,Dipartimento Anestesia e RianimazioneAzienda Ospedaliera San GerardoMonzaItaly
| | - A. Palleschi
- Unità Operativa di Chirurgia ToracicaFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - A. Vargiolu
- Dipartimento Anestesia e RianimazioneAzienda Ospedaliera San GerardoMonzaItaly
| | - B. Safaee Fakhr
- Dipartimento di Anestesia Rianimazione (Intensiva e Sub intensiva) e Terapia del doloreFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - A. Confalonieri
- Dipartimento Anestesia e RianimazioneAzienda Ospedaliera San GerardoMonzaItaly
| | - M. Nosotti
- Dipartimento di Fisiopatologica Medico‐Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly,Unità Operativa di Chirurgia ToracicaFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - S. Gatti
- Centro di Ricerche Chirurgiche PreclinicheFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - S. Ravasi
- Dipartimento Emergenza Urgenza–EASMilanItaly
| | - S. Vesconi
- Direzione Generale Salute LombardiaRegione LombardiaMilanItaly
| | - A. Pesenti
- Scuola di Medicina e ChirurgiaUniversità di Milano‐BicoccaMilanItaly,Dipartimento Anestesia e RianimazioneAzienda Ospedaliera San GerardoMonzaItaly
| | - F. Blasi
- Dipartimento di Fisiopatologica Medico‐Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly,Unità Operativa Complessa BroncopneumologiaFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - L. Santambrogio
- Dipartimento di Fisiopatologica Medico‐Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly,Unità Operativa di Chirurgia ToracicaFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly
| | - L. Gattinoni
- Dipartimento di Anestesia Rianimazione (Intensiva e Sub intensiva) e Terapia del doloreFondazione IRCCS Ca’ Granda–Ospedale Maggiore PoliclinicoMilanItaly,Dipartimento di Fisiopatologica Medico‐Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly
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7
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Luc JGY, Nagendran J. The evolving potential for pediatric ex vivo lung perfusion. Pediatr Transplant 2016; 20:13-22. [PMID: 26694514 DOI: 10.1111/petr.12653] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2015] [Indexed: 11/28/2022]
Abstract
Despite the rise in the number of adult lung transplantations performed, rates of pediatric lung transplantation remain low. Lung transplantation is an accepted therapy for pediatric end-stage lung disease; however, it is limited by a shortage of donor organs. EVLP has emerged as a platform for assessment and preservation of donor lung function. EVLP has been adopted in adult lung transplantation and has successfully led to increased adult lung transplantations and donor lung utilization. We discuss the future implications of EVLP utilization, specifically, its potential evolving role in overcoming donor shortages in smaller children and adolescents to improve the quality and outcomes of lung transplantation in pediatric patients.
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Affiliation(s)
- Jessica G Y Luc
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Mazankowski Alberta Heart Institute, Edmonton, AB, Canada.,Alberta Transplant Institute, Edmonton, AB, Canada.,Canadian National Transplant Research Program, Edmonton, AB, Canada
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Liersch-Nordqvist A, Ingemansson R, Pierre L, Hlebowicz J, Lindstedt S. Lungs exposed to 1 hour warm ischemia without heparin before harvesting might be suitable candidates for transplantation. J Cardiothorac Surg 2015; 10:131. [PMID: 26500001 PMCID: PMC4619285 DOI: 10.1186/s13019-015-0339-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 10/05/2015] [Indexed: 11/17/2022] Open
Abstract
Background The limiting factor for lung transplantation is the lack of donor organs. The usage of lungs from donation after cardiac death (DCD) would dramatically increase donor availability. In the present paper we wanted to investigate lungs exposed to 1 h of warm ischemia without heparin followed by flush-perfusion and cold storage compared to lungs harvested from heart beating donors (HBD) using standard harvesting technique. Methods Twelve Swedish domestic pigs were randomized into two groups. Six pigs (DCD group) underwent ventricular fibrillation and were then left untouched for 1 h after declaration of death. They did not receive heparin. The lungs were then harvested and flush-perfused with Perfadex® solution and the organs were stored at 8 °C for 4 h. Six pigs (HBD group) received heparin and the lungs were harvested and flush-perfused with Perfadex® solution and the organs were stored at 8 °C for 4 h. Lung function was evaluated, using ex vivo lung perfusion (EVLP), with blood gases at different oxygen levels, pulmonary vascular resistance (PVR), lung weight, and macroscopic appearance. Results At FiO2 1.0, the PaO2 in the DCD group was 51.7 ± 2.0 kPa and in the HBD group 68.6 ± 2.4 kPa (p < 0.01). Significantly lower PVR levels were measured in the DCD group (372 ± 31 dyne x s/cm5) compared to the HBD group (655 ± 45 dyne x s/cm5) (p < 0.001). There was no significant difference between groups in weight, compliance or signs of pulmonary thrombosis or embolization. Conclusions It seems as if DCD lungs exposed to 1 h of warm ischemia before 4 h of cold storage has satisfying oxygenation capacity, low PVR, normal weight and no signs of thrombosis or embolization. According to our study it seems as lungs exposed to 1 h warm ischemia without heparin might be good candidates for transplantation.
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Affiliation(s)
- Annika Liersch-Nordqvist
- Department of Pediatric Anesthesia and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
| | - Richard Ingemansson
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Leif Pierre
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Joanna Hlebowicz
- Department of Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden.
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9
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Pierre L, Lindstedt S, Ingemansson R. Ventilation in situ after cardiac death improves pulmonary grafts exposed to 2 hours of warm ischemia. SCAND CARDIOVASC J 2015; 49:293-8. [DOI: 10.3109/14017431.2015.1052549] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Leif Pierre
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Lund University, Sweden
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Lund University, Sweden
| | - Richard Ingemansson
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Lund University, Sweden
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Abstract
Lung transplantation (LTx) is the definitive treatment of patients with end-stage lung disease. Availability of donor lungs remains the primary limitation and leads to substantial wait-list mortality. Efforts to expand the donor pool have included a resurgence of interest in the use of donation after cardiac death (DCD) lungs. Unique in its physiology, lung viability seems more tolerant to the variable durations of ischemia that occur in DCD donors. Initial experience with DCD LTx is promising and, in combination with ex vivo lung perfusion systems, seems a valuable opportunity to expand the lung donor pool.
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11
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Krutsinger D, Reed RM, Blevins A, Puri V, De Oliveira NC, Zych B, Bolukbas S, Van Raemdonck D, Snell GI, Eberlein M. Lung transplantation from donation after cardiocirculatory death: a systematic review and meta-analysis. J Heart Lung Transplant 2014; 34:675-84. [PMID: 25638297 DOI: 10.1016/j.healun.2014.11.009] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 10/14/2014] [Accepted: 11/04/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Lung transplantation (LTx) can extend life expectancy and enhance the quality of life for select patients with end-stage lung disease. In the setting of donor lung shortage and waiting list mortality, the interest in donation after cardiocirculatory death (DCD) is increasing. We performed a systematic review and meta-analysis to compare outcomes between DCD and conventional donation after brain death (DBD). METHODS PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and ClinicalTrials.gov were searched. We identified original research studies with 1-year post-transplant survival data involving >5 DCD transplants. We performed meta-analyses examining 1-year survival, primary graft dysfunction, and acute rejection after LTx. RESULTS We identified 519 citations; 11 observational cohort studies met our inclusion criteria for systematic review, and 6 met our inclusion criteria for meta-analysis. There were no differences found in 1-year mortality after LTx between DCD and DBD cohorts in individual studies or in the meta-analysis (DCD [n = 271] vs DBD [n = 2,369], relative risk [RR] 0.88, 95% confidence interval [CI] 0.59-1.31, p = 0.52, I(2) = 0%). There was also no difference between DCD and DBD in a pooled analysis of 5 studies reporting on primary graft dysfunction (RR 1.09, 95% CI 0.68-1.73, p = 0.7, I(2) = 0%) and 4 studies reporting on acute rejection (RR 0.72, 95% CI 0.49-1.05, p = 0.09, I(2) = 0%). CONCLUSIONS Survival after LTx from DCD is comparable to survival after LTx from DBD in observational cohort studies. DCD appears to be a safe and effective method to expand the donor pool.
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Affiliation(s)
| | - Robert M Reed
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, Maryland
| | - Amy Blevins
- Hardin Library for the Health Sciences, University of Iowa, Iowa City, Iowa
| | - Varun Puri
- Department of Surgery, Washington University, St. Louis, Missouri
| | - Nilto C De Oliveira
- Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Bartlomiej Zych
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, United Kingdom
| | - Servet Bolukbas
- Department of Thoracic Surgery, Dr. Korst Schmidt Klinik, Wiesbaden, Germany
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery and Lung Transplant Unit, University Hospitals Leuven, Leuven, Belgium
| | - Gregory I Snell
- Lung Transplant Service, Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Melbourne, Australia
| | - Michael Eberlein
- Department of Medicine, University of Iowa, Iowa City, Iowa; Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa, Iowa City, Iowa.
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Stanzi A, Neyrinck A, Somers J, Cauwenberghs H, Verbeken E, Santambrogio L, Van Raemdonck D. Do we need to cool the lung graft after ex vivo lung perfusion? A preliminary study. J Surg Res 2014; 192:647-55. [PMID: 25201574 DOI: 10.1016/j.jss.2014.07.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/26/2014] [Accepted: 07/31/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND After normothermic ex vivo lung perfusion (EVLP), pulmonary grafts are usually flush-cooled and stored on ice until implantation although evidence for this practice lacks. We compared outcomes between 2 post-EVLP preservation strategies in a porcine left single-lung transplantation model. MATERIAL AND METHODS After cold flush and 2-h EVLP, donor lungs were prepared and split. In [C], (n = 5) lungs cooled on device to 15°C were preserved in ice-water; in [W] (n = 5), lungs were disconnected from EVLP at 37°C and kept at room temperature. The left lung was transplanted in a recipient animal. Posttransplant, 6 h-monitoring included hourly assessment of pulmonary vascular resistance, pulmonary artery pressure, plateau airway pressure, compliance, and oxygenation before and after exclusion of the right lung. Lung biopsies and bronchoscopy with bronchoalveolar lavage (BAL) were performed at retrieval, at the end of EVLP (R lung), and 1 and 6 h after reperfusion (L lung). RESULTS Lungs in [W] showed the highest compliance (P < 0.05) and the lowest plateau airway pressure (not statistically significant) throughout the whole reperfusion period. Oxygenation and pulmonary artery pressure were similar between groups. Pulmonary vascular resistance was stable in [C], but rose after reperfusion in [W]. Histologic signs of lung injury and BAL neutrophilia were more pronounced in [C] at 1 h (not statistically significant and P < 0.05, respectively). BAL cytokine levels and lung tissue expression of intercellular adhesion molecule 1 did not differ between groups. CONCLUSIONS Normothermic preparation after EVLP results in similar graft performances compared with lung cooling after EVLP.
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Affiliation(s)
- Alessia Stanzi
- Laboratory for Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, KU Leuven University, Leuven, Belgium; Department of Thoracic Surgery, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Arne Neyrinck
- Laboratory for Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, KU Leuven University, Leuven, Belgium; Department of Anesthesia, University Hospitals Leuven, Leuven, Belgium
| | - Jana Somers
- Laboratory for Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, KU Leuven University, Leuven, Belgium
| | - Hans Cauwenberghs
- Department of Anesthesia, University Hospitals Leuven, Leuven, Belgium
| | - Eric Verbeken
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Luigi Santambrogio
- Department of Thoracic Surgery, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Dirk Van Raemdonck
- Laboratory for Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, KU Leuven University, Leuven, Belgium; Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.
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13
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Retrograde flush is more protective than heparin in the uncontrolled donation after circulatory death lung donor. J Surg Res 2013; 187:316-23. [PMID: 24378013 DOI: 10.1016/j.jss.2013.11.1100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 11/15/2013] [Accepted: 11/20/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Formation of microthrombi after circulatory arrest is a concern for the development of reperfusion injury in lung recipients from donation after circulatory death (DCD) donors. In this isolated lung reperfusion study, we compared the effect of postmortem heparinization with preharvest retrograde pulmonary flush or both. METHODS Domestic pigs (n = 6/group) were sacrificed by ventricular fibrillation and left at room temperature for 1 h. This was followed by 2.5 h of topical cooling. In control group [C], no heparin and no pulmonary flush were administered. In group [R], lungs were flushed with Perfadex in a retrograde way before explantation. In group [H], heparin (300 IU/kg) was administered 10 min after cardiac arrest followed by closed chest massage for 2 min. In the combined group, animals were heparinized and the lungs were explanted after retrograde flush [HR]. The left lung was assessed for 60 min in an ex vivo reperfusion model. RESULTS Pulmonary vascular resistance at 50 and 55 min was significantly lower in [R] and [HR] groups compared with [C] and [H] groups (P < 0.01 and P < 0.001) and at 60 min in [R], [H], and [HR] groups compared with [C] group (P < 0.001). Oxygenation, compliance, and plateau airway pressure were more stable in [R] and [HR] groups. Plateau airway pressure was significantly lower in [R] group compared with the [H] group at 60 min (P < 0.05). No significant differences in wet-dry weight ratio were observed between the groups. CONCLUSIONS This study suggests that preharvest retrograde flush is more protective than postmortem heparinization to prevent reperfusion injury in lungs recovered from donation after circulatory death donors.
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Gries CJ, White DB, Truog RD, Dubois J, Cosio CC, Dhanani S, Chan KM, Corris P, Dark J, Fulda G, Glazier AK, Higgins R, Love R, Mason DP, Nakagawa TA, Shapiro R, Shemie S, Tracy MF, Travaline JM, Valapour M, West L, Zaas D, Halpern SD. An official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: ethical and policy considerations in organ donation after circulatory determination of death. Am J Respir Crit Care Med 2013; 188:103-9. [PMID: 23815722 DOI: 10.1164/rccm.201304-0714st] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Donation after circulatory determination of death (DCDD) has the potential to increase the number of organs available for transplantation. Because consent and management of potential donors must occur before death, DCDD raises unique ethical and policy issues. OBJECTIVES To develop an ethics and health policy statement on adult and pediatric DCDD relevant to critical care and transplantation stakeholders. METHODS A multidisciplinary panel of stakeholders was convened to develop an ethics and health policy statement. The panel consisted of representatives from the American Thoracic Society, Society of Critical Care Medicine, International Society for Heart and Lung Transplantation, Association of Organ Procurement Organizations, and the United Network of Organ Sharing. The panel reviewed the literature, discussed important ethics and health policy considerations, and developed a guiding framework for decision making by stakeholders. RESULTS A framework to guide ethics and health policy statement was established, which addressed the consent process, pre- and post mortem interventions, the determination of death, provisions of end-of-life care, and pediatric DCDD. CONCLUSIONS The information presented in this Statement is based on the current evidence, experience, and clinical rationale. New clinical research and the development and dissemination of new technologies will eventually necessitate an update of this Statement.
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Wallinder A, Steen S, Liden H, Hansson C, Hussein AA, Sjöberg T, Dellgren G. Heparin does not improve graft function in uncontrolled non-heart-beating lung donation: an experimental study in pigs. Eur J Cardiothorac Surg 2012; 43:413-9. [DOI: 10.1093/ejcts/ezs364] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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16
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Cypel M, Yeung JC, Keshavjee S. Novel approaches to expanding the lung donor pool: donation after cardiac death and ex vivo conditioning. Clin Chest Med 2011; 32:233-44. [PMID: 21511086 DOI: 10.1016/j.ccm.2011.02.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Two novel approaches have been developed to potentially increase the availability of donor lungs for lung transplantation. In the first approach, lungs from donation after cardiac death (DCD) donors are used to increase the quantity of organ donors. In the second approach, a newly developed normothermic ex vivo lung perfusion (EVLP) technique is used as a means of reassessing the adequacy of lung function from DCD and from high-risk brain death donors prior to transplantation. This EVLP technique can also act as a platform for the delivery of novel therapies to repair injured organs ex vivo.
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Affiliation(s)
- Marcelo Cypel
- Division Thoracic Surgery, Toronto Lung Transplant Program, Toronto General Hospital, University of Toronto, Toronto, M5G 2C4, Canada
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17
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Gomez-de-Antonio D, Varela A. Non-heart-beating donation in Spain. Gen Thorac Cardiovasc Surg 2011; 59:1-5. [DOI: 10.1007/s11748-010-0661-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Accepted: 06/21/2010] [Indexed: 11/28/2022]
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18
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Puri V, Scavuzzo M, Guthrie T, Hachem R, Krupnick AS, Kreisel D, Patterson GA, Meyers BF. Lung Transplantation and Donation After Cardiac Death: A Single Center Experience. Ann Thorac Surg 2009; 88:1609-14; discussion 1614-5. [DOI: 10.1016/j.athoracsur.2009.06.039] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 06/03/2009] [Accepted: 06/04/2009] [Indexed: 11/30/2022]
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19
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De Vleeschauwer S, Van Raemdonck D, Vanaudenaerde B, Vos R, Meers C, Wauters S, Coosemans W, Decaluwe H, De Leyn P, Nafteux P, Dupont L, Lerut T, Verleden G. Early Outcome After Lung Transplantation From Non–Heart-Beating Donors is Comparable to Heart-Beating Donors. J Heart Lung Transplant 2009; 28:380-7. [DOI: 10.1016/j.healun.2009.01.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 12/17/2008] [Accepted: 01/14/2009] [Indexed: 12/21/2022] Open
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20
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Stern M, Souilamas R, Tixier D, Mal H. [Lung transplantation: supply and demand in France]. Rev Mal Respir 2009; 25:953-65. [PMID: 18971802 DOI: 10.1016/s0761-8425(08)74412-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION For a decade lung transplantation has suffered from a lack of donor organs which aroused a national debate and led to planned action in collaboration with The French National Agency for Transplantation. BACKGROUND Analysis of the stages of the process from potential donor to lung transplantation identified lung procurement as the main priority. An increase in the number of potential lung donors and revision of the acceptance criteria led to a doubling of the annual rate of lung transplantation in less than two years. VIEWPOINTS In the near future we may solve the problem of donor family refusals and establish scientifically based criteria for lung acceptance to increase the rate of lung transplantation. Transplantation from non heart-beating donors and the reconditioning of ex vivo non acceptable lungs might supply additional organs to fulfill demand in the long term. CONCLUSIONS The rate of lung transplantation activity in France doubled as the result of a dramatic increase of donor lung proposals. The current improvement in the results of lung transplantation might create new demands and generate future difficulties in the supply of donor lungs. New approaches, such as transplantation from non heart-beating donors and reconditioning ex vivo non acceptable lungs, should be examined in the near future.
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Affiliation(s)
- M Stern
- Service de Pneumologie, Hôpital Foch, Suresnes, France.
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21
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Lung transplantation using donors after cardiac death. Curr Opin Organ Transplant 2007. [DOI: 10.1097/mot.0b013e3282eff56d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Oto T, Levvey B, McEgan R, Davies A, Pilcher D, Williams T, Marasco S, Rosenfeldt F, Snell G. A practical approach to clinical lung transplantation from a Maastricht Category III donor with cardiac death. J Heart Lung Transplant 2007; 26:196-9. [PMID: 17258156 DOI: 10.1016/j.healun.2006.11.599] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Revised: 08/22/2006] [Accepted: 11/21/2006] [Indexed: 11/25/2022] Open
Abstract
Although donation after cardiac death (DCD) has the potential to provide a novel source of organs for lung transplantation, even in a controlled DCD situation such as a Maastricht Category III donor (withdrawal of treatment), the limited time frame available after the declaration of death to initiate procurement and preservation remains challenging. Indeed, no publication has detailed the exact time frames and technique applicable for successful Maastricht Category III DCD lung procurement. In this patient report, withdrawal of life-support treatment and death certification was performed in the intensive care unit and the lungs were procured in an operating room 49 minutes after cardiac arrest and successfully transplanted (cold ischemia time <6 hours) into a severely ill recipient with primary pulmonary hypertension.
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Affiliation(s)
- Takahiro Oto
- Lung Transplant Service, The Alfred Hospital and Monash University, Melbourne, Australia
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23
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Rega FR, Wuyts WA, Vanaudenaerde BM, Jannis NC, Neyrinck AP, Verleden GM, Lerut TE, Van Raemdonck DEM. Nebulized N-Acetyl Cysteine Protects the Pulmonary Graft Inside the Non–Heart-Beating Donor. J Heart Lung Transplant 2005; 24:1369-77. [PMID: 16143259 DOI: 10.1016/j.healun.2004.10.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2004] [Revised: 10/11/2004] [Accepted: 10/11/2004] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The use of lungs from non-heart-beating donors (NHBD) might significantly alleviate the organ shortage. The tolerable warm ischemic period after cardiac arrest, however, is limited to approximately 1 hour. If the lung could be safely protected inside the cadaver, this time period may be prolonged. This would help to obtain family consent and to organize organ retrieval. METHODS Pigs (30.8 +/- 0.6 kg) were killed, left untouched for 3 hours, and divided into 3 groups. Nebulized N-acetyl cysteine (NAC) (300 mg), a precursor of the antioxidant agent glutathione, was administered during 10 minutes before death in Group I (NAC-NHBD, n = 6) and 15 minutes after death in Group II (NHBD-NAC, n = 6). In the control group, no aerosol was administered (NHBD, n = 6). After a warm ischemic interval of 3 hours, both lungs in all groups were topically cooled for 1 hour. Thereafter, the left lung was prepared for evaluation in an isolated reperfusion circuit. Hemodynamic, aerodynamic, and oxygenation parameters were measured. Wet-to-dry weight ratio (W/D) was calculated after reperfusion. The right lung was used to measure reduced glutathione (GSH) and oxidized glutathione (GSSG) levels (micromol/g) in lung homogenates and total protein levels in bronchial lavage fluid. RESULTS Pulmonary vascular resistance, mean airway pressure, and W/D were significantly decreased in NAC-NHBD (1930 +/- 144 Dynes x sec x cm(-5), 14.2 +/- 0.5 cm H2O, and 7.4 +/- 0.4; p < 0.01, 0.01, and 0.05, respectively) and NHBD-NAC (1837 +/- 180 Dynes x sec x cm(-5), 13.3 +/- 1.2 cm H2O, and 7.3 +/- 0.3; p < 0.01, 0.05, and 0.05, respectively) when compared with the control group (5051 +/- 530 Dynes x sec x cm(-5), 17 +/- 0.4 cm H2O, 8.5 +/- 0.1, respectively). GSH/GSSG ratio was significantly higher and protein levels were significantly lower in NAC-NHBD (1.7 +/- 0.1 and 1315 +/- 60 microg/ml; p < 0.05 and 0.05, respectively) and NHBD-NAC (1.7 +/- 0.2 and 1475 +/- 159 microg/ml; p < 0.05 and 0.05, respectively) when compared with the control group (1.2 +/- 0.1 and 2150 +/- 200 microg/ml). CONCLUSIONS Nebulized NAC administered before or shortly after death attenuates early ischemia reperfusion injury via upregulation of glutathione. NAC might be a promising tool to protect the pulmonary graft from both controlled and uncontrolled NHBD.
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Affiliation(s)
- Filip R Rega
- Center for Experimental Surgery and Anesthesiology, Katholieke Universiteit Leuven, Leuven, Belgium
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Wittwer T, Franke UFW, Fehrenbach A, Ochs M, Sandhaus T, Schuette A, Richter S, Dreyer N, Knudsen L, Müller T, Schubert H, Richter J, Wahlers T. Donor pretreatment using the aerosolized prostacyclin analogue iloprost optimizes post-ischemic function of non-heart beating donor lungs. J Heart Lung Transplant 2005; 24:371-8. [PMID: 15812907 DOI: 10.1016/j.healun.2004.02.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Ischemia-reperfusion injury accounts for one-third of early deaths after lung transplantation. To expand the limited donor pool, lung retrieval from non-heart beating donors (NHBD) has been introduced recently. However, because of potentially deleterious effects of warm ischemia on microvascular integrity, use of NHBD lungs is limited by short tolerable time periods before preservation. After intravenous prostanoids are routinely used to ameliorate reperfusion injury, the latest evidence suggests similar efficacy of inhaled prostacyclin. Therefore, the impact of donor pretreatment with the prostacyclin analogue iloprost on postischemic NHBD lung function and preservation quality was evaluated. METHODS Asystolic pigs (5 per group) were ventilated for 180 minutes of warm ischemia (Group 2). In Group 3, 100 microg iloprost was aerosolized during the final 30 minutes of ventilation with a novel mobile ultrasonic nebulizer. Lungs were then retrogradely preserved with Perfadex and stored for 3 hours. After left lung transplantation and contralateral lung exclusion, hemodynamics, rO2/FiO2, and dynamic compliance were monitored for 6 hours and compared with sham-operated controls (Group 1). Pulmonary edema was determined both stereologically and by wet-to-dry weight ratio (W/D). Statistics comprised analysis of variance with repeated measures and Mann-Whitney test. RESULTS Flush preservation pressures, dynamic compliance, inspiratory pressures, and W/D were significantly superior in iloprost-treated lungs, and oxygenation and pulmonary hemodynamics were comparable between groups. Stereology revealed a trend toward lower intraalveolar edema formation in iloprost-treated lungs compared with untreated grafts. CONCLUSIONS Alveolar deposition of Iloprost and NHBD lungs before preservation ameliorates postischemic edema and significantly improves lung compliance. This easily applicable innovation approach, which uses a mobile ultrasonic nebulizer, offers an important strategy for improvement of pulmonary preservation quality and might expand the pool of donor lungs.
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Affiliation(s)
- Thorsten Wittwer
- Department of Cardiothoracic and Vascular Surgery, Friedrich-Schiller University, Jena, Germany.
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25
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Rega FR, Vanaudenaerde BM, Wuyts WA, Jannis NC, Verleden GM, Lerut TE, Van Raemdonck DEM. IL-1β in bronchial lavage fluid is a non-invasive marker that predicts the viability of the pulmonary graft from the non-heart-beating donor. J Heart Lung Transplant 2005; 24:20-8. [PMID: 15653374 DOI: 10.1016/j.healun.2003.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2003] [Revised: 10/06/2003] [Accepted: 10/10/2003] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Viability testing of the pulmonary graft retrieved from the non-heart-beating donor (NHBD) is mandatory for successful outcome after lung transplantation. Functional assessment by ex vivo reperfusion, however, remains a cumbersome procedure. In this study, therefore, we wanted to investigate the possible value of the proinflammatory cytokines interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) measured in bronchial lavage fluid (BLF) in predicting functional outcome of the pulmonary graft after reperfusion. METHODS Domestic pigs (29.9 +/- 0.56 kg) were sacrificed and divided in 5 groups (n = 5/group). In the non-ischemic group (NHBD-0), the heart-lung block was explanted immediately. In the other groups the animals were left untouched with increasing time intervals (1 hour = NHBD-1; 2 hours = NHBD-2; 3 hours = NHBD-3). Thereafter both lungs were cooled topically via chest drains up to a total ischemic interval of 4 hours. Finally, in the heart-beating donor group lungs were flushed and stored for 4 hours (4 degrees C) [HBD]. BLF samples were taken from the right lung in all groups after explantation for measurement of IL-1beta and TNF-alpha and the left lung was prepared for evaluation in an isolated reperfusion circuit. Haemodynamic, aerodynamic and oxygenation parameters were measured. Wet-to-dry weight ratio (W/D) was calculated after reperfusion. RESULTS Graft function deteriorated with increasing time intervals after death. A strong correlation was found between the increase of IL-1beta concentration measured in BLF and the increase in pulmonary vascular resistance (r = 0.80), mean airway pressure (r = 0.74) and wet-to dry weight ratio (r = 0.78); (p < 0.0001, for all parameters). No significant differences in TNF-alpha levels in BLF were observed amongst groups (p = 0.933). CONCLUSIONS IL-1beta in BLF prior to reperfusion correlated well with graft function and may therefore be a useful, non-invasive marker that can predict the viability of the pulmonary graft from the NHBD.
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Affiliation(s)
- Filip R Rega
- Center for Experimental Surgery and Anesthesiology, Katholieke Universiteit Leuven, Leuven, Belgium
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26
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Van Raemdonck DEM, Rega FR, Neyrinck AP, Jannis N, Verleden GM, Lerut TE. Non-heart-beating donors. Semin Thorac Cardiovasc Surg 2004; 16:309-21. [PMID: 15635535 DOI: 10.1053/j.semtcvs.2004.09.014] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The widespread application of lung transplantation is limited by the shortage of suitable donor organs resulting in longer waiting times for listed patients with a substantial risk of dying before transplantation. To overcome this critical organ shortage, some transplant programs have now begun to explore the use of lungs from circulation-arrested donors, so called non-heart-beating donors (NHBDs). This review outlines the different categories of NHBDs, the relevant published experimental data that support the use of lungs coming from these donors and the clinical experience worldwide so far. Techniques for NHBD lung preservation and pretransplant functional assessment are reviewed. Ethical issues involved in transplanting lungs from asystolic donors are discussed.
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Affiliation(s)
- Dirk E M Van Raemdonck
- Thoracic Surgical Research Unit, Center for Experimental Surgery and Anaesthesiology, Catholic University, Leuven, Belgium.
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27
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Loehe F, Preissler G, Annecke T, Bittmann I, Jauch KW, Messmer K. CONTINUOUS INFUSION OF NITROGLYCERIN IMPROVES PULMONARY GRAFT FUNCTION OF NON???HEART-BEATING DONOR LUNGS. Transplantation 2004; 77:1803-8. [PMID: 15223895 DOI: 10.1097/01.tp.0000131155.81609.37] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The warm ischemic period of lungs harvested from a non-heart-beating donor (NHBD) results in an increased ischemia-reperfusion injury after transplantation. The intravenous application of nitroglycerin (NTG), a nitric oxide (NO) donor, proved to be beneficial during reperfusion of lung grafts from heart-beating donors. The objective of the present study was to investigate the effect of nitroglycerin on ischemia-reperfusion injury after transplantation of long-term preserved NHBD-lungs. METHODS Sixteen pigs (body weight, 20-30 kg) underwent left lung transplantation. In the control group (n=5), lungs were flushed (Perfadex, 60 mL/kg) and harvested immediately after cardiac arrest. In the NHBD group (n=5) and the NHBD-NTG group (n=6), lungs were flushed 90 min (warm ischemia) after cardiac arrest. After a total ischemia time of 19 hr, lungs were reperfused and graft function was observed for 5 hr. Recipient animals in the NHBD-NTG group received 2 microg/kg/min of NTG administered intravenously during the observation period starting 5 min before reperfusion. Tissue specimens and bronchoalveolar lavage fluid (BALF) were obtained at the end of the observation period. RESULTS Compared with the control group, pulmonary gas exchange was significantly impaired in the NHBD group, whereas graft function in the NHBD-NTG group did not change. Leukocyte fraction and protein concentration in the BALF and histologic alteration of the NHBD-NTG group were not different from controls. CONCLUSIONS Continuous infusion of NTG in the early reperfusion period improves pulmonary graft function of NHBD lungs after long-term preservation. The administration of an NO donor during reperfusion may favor the use of NHBD lungs to alleviate the critical organ shortage in lung transplantation.
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Affiliation(s)
- Florian Loehe
- Department of Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, D-81377 Munich, Germany.
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Wittwer T, Franke U, Fehrenbach A, Meyer D, Sandhaus T, Pfeifer F, Dreyer N, Mueller T, Schubert H, Richter J, Wahlers T. Impact of retrograde graft preservation in perfadex-based experimental lung transplantation. J Surg Res 2004; 117:239-48. [PMID: 15047129 DOI: 10.1016/j.jss.2003.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Optimal preservation of postischemic organ function is a continuing challenge in clinical lung transplantation. Retrograde instillation of preservation solutions has theoretical advantages to achieve a homogeneous distribution in the lung due to perfusion of both the pulmonary and the bronchial circulation. Thus far, no systematic screening studies followed by in vivo large animal reevaluation including stereological analysis of intrapulmonary edema exist concerning the influence of retrograde preservation on postischemic lung function after preservation with low potassium dextran (LPD) solution (Perfadex). MATERIALS AND METHODS For initial screening in an extracorporeal rat model eight lungs, each, were preserved for 4 h using antegrade or retrograde preservation with LPD solution (Perfadex; PER(ant)/PER(ret)). Respiratory and hemodynamic results after reperfusion were compared to low-potassium Euro-Collins (LPEC). For systematic reevaluation, five pig lungs, each, were preserved correspondingly for 27 h, and results were compared to sham-operated control lungs. In both models, edema formation was quantified stereologically. Statistics comprised different ANOVA models. RESULTS In both models, use of PER(ret) resulted in significantly higher oxygenation capacity, lower inspiratory pressures, and lower amounts of intraalveolar edema as compared to PER(ant). Results of PER(ret) were not different from sham controls in the in vivo model; furthermore, a continuous retrograde elimination of blood clots from pulmonary microcirculation was noticed. CONCLUSIONS Retrograde application of LPD solution (Perfadex) results in significant functional and histological improvement as compared to antegrade perfusion. This innovative technique can be applied very easily in clinical practice and might be an ideal adjunct to further optimize the results after lung transplantation with LPD-based graft protection.
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Affiliation(s)
- Thorsten Wittwer
- Department of Cardiothoracic and Vascular Surgery, Friedrich-Schiller University, 07740 Jena, Germany.
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Rega FR, Jannis NC, Verleden GM, Flameng WJ, Lerut TE, Van Raemdonck DEM. Should we ventilate or cool the pulmonary graft inside the non-heart-beating donor? J Heart Lung Transplant 2004; 22:1226-33. [PMID: 14585384 DOI: 10.1016/s1053-2498(02)01236-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The ideal preservation method during the warm ischemic period in the non-heart-beating donor (NHBD) remains unclear. In this study we compare the protective effect of ventilation vs cooling of the non-perfused pulmonary graft. METHODS Domestic pigs (30.8 +/- 0.35 kg) were divided into 3 groups. In Group I, lungs were flushed with cold Perfadex solution, explanted and stored in saline (4 degrees C) for 4 hours (HBD, n = 5). Pigs in the 2 study groups were killed by myocardial fibrillation and left untouched for 1 hour. Lungs in Group II were ventilated (NHBD-V, n = 5) for 3 hours. Lungs in Group III were topically cooled (NHBD-TC, n = 5) in situ for 3 hours with saline (6 degrees C) infused via intra-pleural drains. Thereafter, the left lungs from all groups were prepared for evaluation. In an isolated circuit the left lungs were ventilated and reperfused via the pulmonary artery (PA) with autologous, hemodiluted, deoxygenated blood. Hemodynamic, aerodynamic and oxygenation parameters were measured at 37.5 degrees C and a PA pressure of 20 mm Hg. The wet:dry weight ratio (W/D) was calculated after reperfusion. RESULTS Pulmonary vascular resistance, oxygenation index and W/D weight ratio were significantly worse in NHBD-V (3,774 +/- 629 dyn sec cm(-5), 3.43 +/- 0.5, 6.98 +/- 0.42, respectively) compared with NHBD-TC (1,334 +/- 140 dyn sec cm(-5), 2.47 +/- 0.14, 5.72 +/- 0.24, respectively; p < 0.01, p < 0.05 and p < 0.05, respectively) and HBD (1,130 +/- 91 dyn sec cm(-5), 2.25 +/- 0.09, 5.23 +/- 0.49, respectively; p < 0.01, p < 0.01 and p < 0.05, respectively groups). No significant differences were observed, however, in any of these parameters between NHBD-TC and HBD (p = 0.46, p = 0.35 and p = 0.12, respectively). CONCLUSION These results indicate that cooling of the pulmonary graft inside the cadaver is the preferred method in an NHBD protocol. It is also confirmed that 1 hour of warm ischemia does not diminish graft function upon reperfusion.
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Affiliation(s)
- Filip R Rega
- Center for Experimental Surgery and Anesthesiology, Catholic University of Leuven, Leuven, Belgium
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Rega FR, Neyrinck AP, Verleden GM, Lerut TE, Van Raemdonck DEM. How long can we preserve the pulmonary graft inside the nonheart-beating donor? Ann Thorac Surg 2004; 77:438-44; discussion 444. [PMID: 14759412 DOI: 10.1016/s0003-4975(03)01343-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The use of lungs from nonheart-beating donors (NHBD) might significantly alleviate the organ shortage. Extending the preharvest interval in NHBD would facilitate distant organ retrieval. We hypothesized that prolonged topical cooling inside NHBD after 60 minutes of initial warm ischemia would not affect the pulmonary graft. METHODS Domestic pigs were anesthetized and divided into three groups (n = 6 in each group). In the control group (HBD), lungs were flushed, explanted, and further stored in low potassium dextran solution (4 degrees C) for 4 hours. In the two study groups pigs were sacrificed by myocardial fibrillation and left untouched for 1 hour. Chest drains were then inserted for topical lung cooling (6 degrees C) for 3 hours (NHBD-TC3) or 6 hours (NHBD-TC6). The left lung in all groups was then prepared for evaluation. In an isolated circuit lungs were ventilated and reperfused through the pulmonary artery. Hemodynamic, aerodynamic, and oxygenation variables were measured 35 minutes after onset of controlled reperfusion. Wet-to-dry weight ratio was calculated. RESULTS No significant differences were observed among the three groups in pulmonary vascular resistance (p = 0.38), mean airway pressure (p = 0.39), oxygenation index (p = 0.62), and wet-to-dry weight ratio (p = 0.09). CONCLUSIONS These data confirm that 1 hour of warm ischemia does not affect the pulmonary graft from NHBD compared with HBD. The preharvest interval can be safely extended up to 7 hours postmortem by additional topical cooling of the graft inside the cadaver. This technique may facilitate distant organ retrieval in NHBD.
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Affiliation(s)
- Filip R Rega
- Center for Experimental Surgery and Anesthesiology, Catholic University of Leuven, Leuven, Belgium
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Wittwer T, Franke UFW, Fehrenbach A, Sandhaus T, Pfeifer F, Dreyer N, Mueller T, Schubert H, Petrow P, Richter J, Wahlers T. Lung Retrieval from Non-Heart-Beating Donors: First Experience with an Innovative Preservation Strategy in a Pig Lung Transplantation Model. Eur Surg Res 2004; 36:1-7. [PMID: 14730216 DOI: 10.1159/000075067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2003] [Accepted: 07/28/2003] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Lung transplantation is limited by the scarcity of donor organs. Lung retrieval from non-heart-beating donors (NHBD) might extend the donor pool and has been reported recently. However, no studies in NHBD exist using the novel approach of retrograde preservation with Perfadex solution. METHODS Heparinized asystolic pigs (n = 5, 30-35 kg) were ventilated for 90 min. The lungs were retrogradely preserved with Perfadex solution and stored inflated at 4 degrees C for 3 h. Left lung transplantation in the recipient was followed by exclusion of the right lung. Results were compared to sham-operated animals. Oxygenation, hemodynamics and dynamic compliance were monitored for 4 h. Infiltration of polymorphonuclear cells (PMNs) and stereological quantification of alveolar edema was performed. Statistical analysis comprised Kruskal-Wallis and Mann-Whitney tests and ANOVA analysis with repeated measures. RESULTS No mortality was observed. During preservation, continuous elimination of blood clots via the pulmonary artery venting site was observed. Oxygenation and compliance were similar between groups, but sham controls showed significantly lower pulmonary vascular resistance. Stereological quantification revealed higher volume fractions of intra-alveolar edema in NHBD grafts, while PMN infiltration was comparable to sham controls. CONCLUSIONS Use of NHBD lungs results in excellent outcome after 90 min of warm ischemia followed by retrograde preservation with Perfadex solution. This novel approach can optimize lung preservation by eliminating clots from the pulmonary circulation and might clinically be considered in brain-dead organ donors who become hemodynamically unstable prior to organ harvest. Further trials with longer warm and cold ischemic periods are necessary to further elucidate this promising approach to donor pool expansion.
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Affiliation(s)
- Th Wittwer
- Department of Cardiothoracic and Vascular Surgery, Friedrich Schiller University, Jena, Germany.
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Abstract
Access to lung transplantation is severely limited by a scarcity of suitable donors, resulting in increasing numbers of deaths on the heart and lung transplant waiting lists, and strict selection criteria for recipients. Unlike some other solid organs, the lung may be ideally suited to retrieval for transplant following substantial intervals after circulatory arrest. This may be because lung parenchymal cells do not rely on perfusion for cellular respiration. This review outlines the relevant published experimental data that addresses the concept that lungs might be suitable for transplant even if retrieved from non-heart-beating donors (NHBDs), and the small published clinical experience with NHBDs as lung donors. Aspects of reperfusion injury in this setting are reviewed. The prospect of heart transplant from NHBDs is addressed. The impact of the routine use of NHBDs on lung transplantation is discussed.
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Affiliation(s)
- Thomas M Egan
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599-7065, USA.
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Rega FR, Jannis NC, Verleden GM, Lerut TE, Van Raemdonck DEM. Long-term preservation with interim evaluation of lungs from a non-heart-beating donor after a warm ischemic interval of 90 minutes. Ann Surg 2003; 238:782-92; discussion 792-3. [PMID: 14631215 PMCID: PMC1356160 DOI: 10.1097/01.sla.0000098625.24363.d9] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the value of in situ preservation and ex vivo evaluation of lungs from a non-heart-beating donor (NHBD) prior to long-term cold storage. SUMMARY BACKGROUND DATA The use of pulmonary grafts from NHBD might alleviate the organ shortage. However, viability testing of these grafts is mandatory to transplant only those lungs with excellent function. METHODS Pigs were divided into two groups. In the control group, lungs were flushed, explanted, and stored for 4 hours (4 degrees C). In the study group, pigs were killed and left untouched for 90 minutes. Thereafter, the lungs were cooled for 150 minutes via chest drains. Graft function of the left lung in both groups was assessed in an isolated ventilation and reperfusion circuit 4 hours after death. The lung was then cooled and stored. Twenty-four hours after death, the pulmonary graft was reassessed in the same model. RESULTS We did not observe a statistical significant difference between the two groups in pulmonary vascular resistance, mean airway pressure, and partial oxygen tension at each time point. There was also no statistical significant difference in wet-to-dry weight ratio. Finally, no statistical difference was found within both groups comparing the assessment at 24 hours with the interim evaluation at 4 hours. CONCLUSIONS These data demonstrate that: 1) 90 minutes of warm ischemia and 150 minutes of intrapleural cooling do not affect pulmonary graft function; and 2) NHBD lungs can be safely preserved up to 24 hours. Finally, we have demonstrated that interim ex vivo evaluation of NHBD lungs is a valid and safe method to assess graft function.
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Affiliation(s)
- Filip R Rega
- Center for Experimental Surgery and Anesthesiology, University Hospital Gasthuisberg, Leuven, Belgium
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Rega FR, Vandezande EJ, Jannis NC, Verleden GM, Lerut TE, Van Raemdonck DEM. The role of leukocyte depletion in ex vivo evaluation of pulmonary grafts from (non-)heart-beating donors. Perfusion 2003; 18 Suppl 1:13-21. [PMID: 12708761 DOI: 10.1191/0267659103pf624oa] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
If lungs could be retrieved for transplantation after circulatory arrest, the shortage of donors might be significantly alleviated. An important issue in using lungs from these so-called non-heart-beating donors is the development of a technique to assess their quality prior to transplantation without jeopardizing the life of the recipient. In our laboratory we tested the reliability of an ex vivo model for such an evaluation. We used pig lungs from optimal control animals, in casu heart-beating donors. This model enabled us to preserve and evaluate lungs with perfect function up to 24 hours after death. The intermediate assessment is performed in an isolated circuit where the lungs are being ventilated and reperfused via the pulmonary artery (PA) with autologous and haemodiluted blood. Haemodynamic, aerodynamic and oxygenation parameters are measured at 37.5 degrees C and a maximum PA pressure of 20 mmHg. These data were correlated with premortem values. During this ex vivo evaluation, leukocyte depletion plays an important role since neutrophils have been recognized as critical components in the inflammatory cascade, which is responsible for graft dysfunction soon and long after transplantation.
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Affiliation(s)
- Filip R Rega
- Centre for Experimental Surgery and Anaesthesiology, Catholic University of Leuven, Belgium
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Loehe F, Mueller C, Annecke T, Minor T, Bittmann I, Krombach F, Messmer K. Tissue damage of non-heart-beating donor lungs after long-term preservation: evaluation of histologic alteration, bronchoalveolar lavage, and energy metabolism. Shock 2002; 17:502-7. [PMID: 12069188 DOI: 10.1097/00024382-200206000-00011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Several studies have shown that warm ischemia before short-term preservation of pulmonary grafts from non-heart-beating donors (NHBD) induced morphological changes, but still provided a good pulmonary graft function. The aim of this study was to investigate morphological and metabolic changes of NHBD lungs after long-term preservation. Left lung allotransplantation was performed on 12 native-bred pigs. In the NHBD group, lungs were subjected to 90 min of warm ischemia before harvesting, whereas lungs in the HBD group were harvested immediately after cardiac arrest. After a total ischemic period of 19 h, lungs were reperfused and pulmonary gas exchange was assessed. Bronchoalveolar lavage (BAL) and tissue specimen for wet-to-dry weight (W/D) ratio, histologic examination, and measurement of high-energy phosphates were taken 5 h after reperfusion. All parameters were compared with a sham-operated control group. Five hours after reperfusion, mean paO2 and paCO2 were 288 +/- 52 and 48 +/- 0.8 mmHg, respectively, during isolated ventilation of the pulmonary graft with 100% oxygen in the NHBD group. W/D ratio and high-energy phosphates of the pulmonary graft did not differ between our study groups. Histologic examination showed significant morphological changes in the HBD and NHBD group, but alterations were more pronounced in the NHBD group. The percentage of neutrophils, total protein content, and potassium concentration were significantly elevated in the BAL fluid of the NHBD group. Despite the observed aggravation of cellular injury after long-term preservation, NHBD lungs still performed a good pulmonary graft function.
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Affiliation(s)
- Florian Loehe
- Department of Surgery, Klinikum Grosshadern, Ludwig-Maximillians-University of Munich, Germany
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Affiliation(s)
- D L DeMeo
- Lung Transplant Program, Pulmonary and Critical Care Unit, Bigelow 808, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Yoshimura T, Kawashima M, Nakamura T, Isowa N, Bando T, Hasegawa S, Kondo H, Toyokuni S, Wada H. A novel selectin blocker alleviates oxidative stress of lung reperfusion injury. J Surg Res 2001; 101:91-8. [PMID: 11676561 DOI: 10.1006/jsre.2001.6258] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The importance of reactive oxygen species released through interaction of leukocyte/endothelial cell in ischemia-reperfusion injury of the lung is not yet fully understood. A novel selectin blocker, OJ-R9188, which inhibits the interaction, may alleviate oxidative stress and pulmonary dysfunction after warm ischemia-reperfusion. MATERIALS AND METHODS Rat lungs were reperfused at 37 degrees C for 60 min with an ex vivo model and were divided into three groups (n = 10). In the fresh group, lungs were reperfused immediately after harvest. In the OJ-R (-) and OJ-R (+) groups, lungs were reperfused after warm ischemia at 37 degrees C for 90 min. In the OJ-R (+) group, rats received 100 microg per body of OJ-R9188 intravenously 10 min before the harvest. The electron spin resonance method was used to assess the direct scavenging activity of OJ-R9188. RESULTS Both shunt fractions and wet/dry weight ratios of the lung tissue after reperfusion in the OJ-R (+) group were significantly lower than those in the OJ-R (-) group. Oxidative DNA damage in the alveolar wall of the OJ-R (+) group, assessed by immunohistochemical quantitation of 8-hydroxy-2'-deoxyguanosine, was significantly lower than that of the OJ-R (-) group. Immunostaining of 3-nitro-l-tyrosine, which represents nitric oxide-mediated oxidative damage, was also more intense in the OJ-R (-) group than in the OJ-R (+) group. Direct scavenging activity of OJ-R9188 was not observed, and the number of leukocytes infiltrated to the lung tissue as seen by myeloperoxidase activity was not different between the OJ-R (-) and OJ-R (+) groups. CONCLUSIONS A novel selectin blocker, OJ-R9188, improves pulmonary function after warm ischemia-reperfusion and alleviates reperfusion-induced oxidative alveolar damage.
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Affiliation(s)
- T Yoshimura
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
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Loehe F, Mueller C, Annecke T, Siebel A, Bittmann I, Messmer KF, Schildberg FW. Pulmonary graft function after long-term preservation of non-heart-beating donor lungs. Ann Thorac Surg 2000; 69:1556-62. [PMID: 10881841 DOI: 10.1016/s0003-4975(00)01234-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Critical organ shortage in lung transplantation could be attenuated by the use of non-heart-beating donor (NHBD) lungs. In addition, prolonged ischemic tolerance of the organs would contribute to the alleviation of organ shortage. The aim of this study was to investigate pulmonary graft function of NHBD lungs after long-term hypothermic storage. METHODS Twelve native-bred pigs (bodyweight 20 to 30 kg) underwent left lung allotransplantation. In the heart-beating donor (HBD) group, lungs were harvested immediately after cardiac arrest. In the NHBD group, lungs were subjected to a warm ischemic period of 90 minutes before harvesting. After a total ischemic time of 19 hours, pulmonary grafts in both groups were reperfused and pulmonary graft function was assessed. All values were compared with a sham-operated control group. RESULTS Pulmonary graft function in the HBD group was excellent. In the NHBD group, pulmonary gas exchange was impaired, but still provided good graft function compared with the excellent graft function in the HBD group. Pulmonary vascular resistance was even lower in the NHBD group. In the NHBD group, calculated intrapulmonary shunt fraction (Qs/Qt) was significantly increased compared with the sham-group. Histologic alteration and wet-to-dry ratio did not differ significantly between the HBD and NHBD group. CONCLUSIONS We conclude that NHBD lungs (90 minutes of warm ischemic time) have the potential to alleviate organ shortage in lung transplantation even after an extended total ischemic time.
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Affiliation(s)
- F Loehe
- Department of Surgery, Institute of Pathology, University of Munich, Germany.
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