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Patoir A, Luchez A, Tiffet O, Vercherin P, Grima R, Tronc F, Philit F, Mornex JF, Vergnon JM, Maury JM. Airway complications after lung transplantation: benefit of a conservative bronchoscopy strategy. J Thorac Dis 2020; 12:2625-2634. [PMID: 32642170 PMCID: PMC7330399 DOI: 10.21037/jtd.2020.03.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background After lung transplantation (LT), between 2% and 25% of bronchial anastomoses develop complications requiring therapeutic intervention. The status of healing of both bronchial anastomoses and downhill airways are well described by the French consensual MDS standardized grading system (Macroscopic, Diameter, Suture). We analyzed risks factors for airway complications (AC) after transplantation and the way we managed them. We report here our challenging method of early rigid bronchoscopic intervention with airway stenting on bronchial healing. Methods All single center consecutives LTs were retrospectively analyzed between 2010-2016. Patient-level data (demographic, peri-operative data) and anastomosis-level data (surgical parameters, bronchoscopy findings) were monitored. The incidence and contributive factors of ACs are reported. We also reported modalities of the conservative treatment and outcome. Results A total of 121 LTs were performed, 39 single-lung and 82 bilateral sequential LT. Main indication for LT were cystic fibrosis (45%) and emphysema (25%) and 58 were male patients (n=70). After a waiting period of healing, 28 patients presented AC on 41 anastomoses (prevalence: 23%). A multivariate analysis found as contributive factors of ACs, post-operative infection by Aspergillus [odds ratio (OR) 2.7, 95% confidence interval (CI): 1.08-6.75; P=0.033] at the patient level, and at the anastomosis level, emphysema (OR 2.4, 95% CI: 1.02-5.6; P=0.045), early dehiscence (OR 11.2, 95% CI: 1.7-76; P=0.01) and cold ischemia time >264 min (OR 2.45, 95% CI: 1.08-5.6; P=0.03). All the 41 ACs were managed conservatively with rigid bronchoscopy (range, 1-10), 41 stents (21 in silicone and 20 fully-covered Silicone Expandable Metallic Stents) without major complication. Two AC were still under regular bronchoscopic care and silicone stenting for long left bronchus reason. No surgical intervention was needed. The 2-years overall survival rate where not different between AC group and controls, respectively 85% and 81%. Conclusions Airway healing after transplantation remains a scalable process and the French consensual MDS classification helped us for therapeutic decisions. Rigid bronchoscopy and safety use of current stenting devices may have the pivotal role in the conservative management of ACs, avoiding perilous situation of surgery for AC. Despite a high rate of AC, their favorable evolution may be explained by the cautious care of airway healing and maybe by the use of the Celsior antioxidant solution.
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Affiliation(s)
- Arnaud Patoir
- Department of Thoracic Surgery, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France
| | - Antoine Luchez
- Pneumology Department, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France
| | - Olivier Tiffet
- Department of Thoracic Surgery, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France
| | - Paul Vercherin
- Department of Thoracic Surgery, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France.,Pneumology Department, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France.,Public Health and Medical Informatics Department, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France.,Department of Thoracic Surgery and Lung and Heart-Lung Transplantation, Hospices Civils de Lyon, Lyon, France.,Pneumology and Lung Transplantation Department, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, UMR754, INRA, Lyon, France.,Université de Lyon, Université Jean Monnet de Saint-Etienne, INSERM, U 1059 Sainbiose, F-42023, Saint-Etienne, France
| | - Renaud Grima
- Department of Thoracic Surgery and Lung and Heart-Lung Transplantation, Hospices Civils de Lyon, Lyon, France
| | - François Tronc
- Department of Thoracic Surgery and Lung and Heart-Lung Transplantation, Hospices Civils de Lyon, Lyon, France
| | - François Philit
- Pneumology and Lung Transplantation Department, Hospices Civils de Lyon, Lyon, France
| | - Jean-François Mornex
- Pneumology and Lung Transplantation Department, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, UMR754, INRA, Lyon, France
| | - Jean-Michel Vergnon
- Pneumology Department, Saint-Etienne University Hospital, North Hospital, 42055 Saint Étienne CEDEX 2, France.,Université de Lyon, Université Jean Monnet de Saint-Etienne, INSERM, U 1059 Sainbiose, F-42023, Saint-Etienne, France
| | - Jean-Michel Maury
- Department of Thoracic Surgery and Lung and Heart-Lung Transplantation, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, UMR754, INRA, Lyon, France
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Baron O, Fabre S, Haloun A, Treilhaud M, al Habasch O, Duveau D, Michaud JL, Despins P. Retrospective Clinical Comparison of Celsior Solution to Modified Blood Wallwork Solution in Lung Transplantation for Cystic Fibrosis. Prog Transplant 2016; 12:176-80. [PMID: 12371042 DOI: 10.1177/152692480201200304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objective To compare the preservative effects of Celsior solution and modified blood Wallwork solution in lung transplantation. Methods From 1989 to 2000, 44 lung transplantations for cystic fibrosis were performed: 26 grafts were preserved with modified blood Wallwork solution and 18 with Celsior solution. Results Preoperative status of the 2 groups was similar. The ratio of arterial oxygen to fraction of inspired oxygen and the pulmonary vascular resistance on the first postoperative day did not differ significantly between the 2 groups. Early death was 4% (SD, 20%) in the Wallwork group versus 11% (SD, 32%) in the Celsior group (not significant). No death was related to graft failure. The forced expiratory volume in 1 second during the first month after transplantation was 63% (SD, 19%) in the Wallwork group versus 63% (SD, 16%) in the Celsior group (not significant). Conclusion Because the solution does not need to be prepared on site and does not require blood from the donor, Celsior seems better than Wallwork solution for preserving lung grafts.
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Affiliation(s)
- O Baron
- Thoracic Transplantation Unit, Cardiovascular Surgery Department, Laennec Hospital, Nantes, France
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Gohrbandt B, Avsar M, Warnecke G, Sommer SP, Haverich A, Strueber M. Initial topical cooling followed by backtable Celsior flush perfusion provides excellent early graft function in porcine single lung transplantation after 24 hours of cold ischemia. J Heart Lung Transplant 2013; 32:832-8. [PMID: 23856220 DOI: 10.1016/j.healun.2013.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 05/20/2013] [Accepted: 06/04/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Topical in situ cooling of the donor lungs is a prerequisite for procurement of non-heart-beating donor lungs and may be of interest for living related lung donation. METHODS Twenty-four single lung transplants were performed in 4 groups of Landrace pigs (6 per group). Control LPD, control Celsior and topical cooling in situ, followed by LPD (exLPD) or Celsior (exCel) ex situ flush, were employed. All lungs were perfused antegrade with 1 liter of solution at 4°C. Lungs were stored immersed in preservation solution for 24 hours at 4°C. After transplantation of the left lung, the right recipient bronchus and pulmonary artery were clamped. RESULTS Four of 6 animals each in the LPD and Celsior groups and all 6 animals in both the exLPD and the exCel groups survived the 7-hour reperfusion. The mean oxygenation index was favorably preserved in the exCel group at 7 hours after reperfusion (417 ± 81) over all other groups (LPD 341 ± 133, Celsior 387 ± 86, exLPD 327 ± 76; p < 0.0001). Pulmonary vascular resistance showed significantly lower values in the Celsior and exCel groups (LPD 1,310 ± 620, Celsior 584 ± 194, exLPD 1,035 ± 361, exCel 650 ± 116 dyn/s/cm(5) at 7 hours after reperfusion; p < 0.0001). Consistently, the wet-to-dry lung weight ratio also indicated beneficial graft protection in the exCel group (LPD 8.1 ± 0.8, Celsior 8.4 ± 0.8, exLPD 7.5 ± 1.0, exCel 3.1 ± 0.9; p < 0.0001). CONCLUSION Initial topical cooling followed by backtable perfusion is a sufficient technique for pulmonary graft preservation providing excellent post-transplant function. Celsior subsequent to in-situ topical cooling revealed the most beneficial results in this setting. This combined technique could advance non-heart-beating, living related lung lobe donation and, potentially, regular heart-beating lung donation.
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Affiliation(s)
- Bernhard Gohrbandt
- Hannover Thoracic Transplant Program, Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Menezes AQ, Pêgo-Fernandes PM, Cardoso PFG, Braga KADO, Nepomuceno NA, Pazetti R, Correia AT, Canzian M, Santim JK, Jatene FB. Comparison of Celsior and Perfadex lung preservation solutions in rat lungs subjected to 6 and 12 hours of ischemia using an ex-vivo lung perfusion system. Clinics (Sao Paulo) 2012. [PMID: 23184209 PMCID: PMC3488991 DOI: 10.6061/clinics/2012(11)15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE This study evaluated the performance of lungs that were preserved with different solutions (Celsior, Perfadex or saline) in an ex vivo rat lung perfusion system. METHODS Sixty Wistar rats were anesthetized, anticoagulated and randomized into three groups (n = 20). The rats were subjected to antegrade perfusion via the pulmonary artery with Perfadex, Celsior, or saline, followed by 6 or 12 hours of ischemia (4ºC, n = 10 in each group). Respiratory mechanics, gas exchange and hemodynamics were measured at 10-minute intervals during the reperfusion of heart-lung blocks in an ex vivo system (IL2-Isolated Perfused Rat or Guinea Pig Lung System, Harvard Apparatus, Holliston, Massachusetts, USA; Hugo Sachs Elektronik, Germany) for 60 minutes. The lungs were prepared for histopathology and evaluated for edema following reperfusion. Group comparisons were performed using ANOVA and the Kruskal-Wallis test with a 5% level of significance. RESULTS Gas exchange was not significantly different between lungs perfused with either Perfadex or Celsior at the same ischemic times, but it was very low in lungs that were preserved with saline. Airway resistance was greater in the lungs that were preserved for 12 hours. Celsior lungs that were preserved for 6 and 12 hours exhibited lower airway resistance (p = 0.01) compared to Perfadex lungs. Pulmonary artery pressure was not different between the groups, and no significant differences in histopathology and apoptosis were observed between the groups. CONCLUSIONS Lungs that were preserved with Celsior or Perfadex exhibited similar gas exchange and histopathological findings. Airway resistance was slightly lower in the Celsior-preserved lungs compared with the Perfadex-preserved lungs.
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Affiliation(s)
- Arteiro Queiroz Menezes
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Heart Institute (InCor), São Paulo/SP, Brazil
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Guibert EE, Petrenko AY, Balaban CL, Somov AY, Rodriguez JV, Fuller BJ. Organ Preservation: Current Concepts and New Strategies for the Next Decade. Transfus Med Hemother 2011; 38:125-142. [PMID: 21566713 PMCID: PMC3088735 DOI: 10.1159/000327033] [Citation(s) in RCA: 186] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Accepted: 01/26/2011] [Indexed: 12/12/2022] Open
Abstract
SUMMARY: Organ transplantation has developed over the past 50 years to reach the sophisticated and integrated clinical service of today through several advances in science. One of the most important of these has been the ability to apply organ preservation protocols to deliver donor organs of high quality, via a network of organ exchange to match the most suitable recipient patient to the best available organ, capable of rapid resumption of life-sustaining function in the recipient patient. This has only been possible by amassing a good understanding of the potential effects of hypoxic injury on donated organs, and how to prevent these by applying organ preservation. This review sets out the history of organ preservation, how applications of hypothermia have become central to the process, and what the current status is for the range of solid organs commonly transplanted. The science of organ preservation is constantly being updated with new knowledge and ideas, and the review also discusses what innovations are coming close to clinical reality to meet the growing demands for high quality organs in transplantation over the next few years.
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Affiliation(s)
- Edgardo E. Guibert
- Centro Binacional (Argentina-Italia) de Investigaciones en Criobiología Clínica y Aplicada (CAIC), Universidad Nacional de Rosario, Argentina
| | - Alexander Y. Petrenko
- Department of Cryobiochemistry, Institute for Problems of Cryobiology and Cryomedicine, Ukraine Academy of Sciences, Kharkov, Ukraine
| | - Cecilia L. Balaban
- Centro Binacional (Argentina-Italia) de Investigaciones en Criobiología Clínica y Aplicada (CAIC), Universidad Nacional de Rosario, Argentina
| | - Alexander Y. Somov
- Department of Cryobiochemistry, Institute for Problems of Cryobiology and Cryomedicine, Ukraine Academy of Sciences, Kharkov, Ukraine
| | - Joaquín V. Rodriguez
- Centro Binacional (Argentina-Italia) de Investigaciones en Criobiología Clínica y Aplicada (CAIC), Universidad Nacional de Rosario, Argentina
| | - Barry J. Fuller
- Cell, Tissue and Organ Preservation Unit, Department of Surgery & Liver Transplant Unit, UCL Medical School, Royal Free Hospital Campus, London, UK
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Thoracic organs: current preservation technology and future prospects; part 1: lung. Curr Opin Organ Transplant 2010; 15:150-5. [DOI: 10.1097/mot.0b013e3283373b7e] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ostróżka-Cieślik A, Dolińska B, Ryszka F. Influence of the selected antioxidants on the stability of the Celsior solution used for perfusion and organ preservation purposes. AAPS PharmSciTech 2009; 10:468-75. [PMID: 19381826 DOI: 10.1208/s12249-009-9232-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Accepted: 03/17/2009] [Indexed: 11/30/2022] Open
Abstract
The purpose of the following research was to improve the original Celsior solution in order to obtain a higher degree of stability and effectiveness. The solution was modified by the addition of selected antioxidants such as vitamin C, cysteine, and fumaric acid in the following concentrations: 0.1, 0.3, and 0.5 mmol/l. The solution's stability was estimated using an accelerated stability test based on changes in histidine concentrations in the solution using Pauly's method for determining concentrations. Elevated temperatures, the factor accelerating substances' decomposition reaction rate, were used in the tests. The research was conducted at four temperatures at intervals of 10 degrees C: 60 +/- 0.2 degrees C, 70 +/- 0.2 degrees C, 80 +/- 0.2 degrees C, and 90 +/- 0.2 degrees C. It was stated that the studied substances' decomposition occurred in accordance with the equation for first-order reactions. The function of the logarithmic concentration (log%C) over time was revealed to be rectilinear. This dependence was used to determine the kinetics of decomposition reaction rate parameters (the rate constant of decomposition k, activation energy E (a), and frequency factor A). On the basis of these parameters, the stability of the modified solution was estimated at +5 degrees C. The results obtained show that the proposed antioxidants have a significant effect on lengthening the Celsior solution's stability. The best results were reached when combining two antioxidants: vitamin C and cysteine in 0.5 mmol/l concentrations. As a result, the Celsior solution's stability was lengthened from 22 to 299 days, which is 13.5 times. Vitamin C at a concentration of 0.5 mmol/l increased the solution's stability by 5.2 times (t(90) = 115 days), cysteine at a concentration of 0.5 mmol/l caused a 4.4 times stability increase (t(90) = 96 days), and fumaric acid at a concentration of 0.5 mmol/l extended the stability by 2.1 times (t(90) = 48 days) in relation to the original solution.
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Hypothermic in situ perfusion of the porcine liver using Celsior or Ringer-lactate solution. Langenbecks Arch Surg 2008; 394:143-50. [DOI: 10.1007/s00423-008-0322-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2007] [Accepted: 12/20/2007] [Indexed: 11/26/2022]
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Karam G, Compagnon P, Hourmant M, Despins P, Duveau D, Noury D, Boudjema K. A single solution for multiple organ procurement and preservation. Transpl Int 2005; 18:657-63. [PMID: 15910289 DOI: 10.1111/j.1432-2277.2005.00083.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Two or three different solutions may be used to preserve thoracic and abdominal organs during a single procurement. The aim of this prospective, multi-center, noncomparative study was to evaluate the safety and efficacy of Celsior (study solution, solution S) as a flushing and cold storage solution for both thoracic and abdominal organs. Between August 1999 and July 2000, 72 consecutive multiple-organ procurements were performed using solution S as the sole solution for flushing out and cold-storing thoracic and abdominal grafts. Two hundred and sixty-four grafts were implanted into 245 recipients (131 kidneys, 9 kidney-pancreases, 69 livers, 34 hearts and 6 heart-lungs). The mean cold ischemia time was 21 h for kidneys (26%>24 h); 11 h 26 min for pancreases, 9 h 16 min for livers (23%>12 h), and 2 h 58 min for hearts and lungs. No cardiac failure or arrhythmia occurred on graft reperfusion. Fourteen percent of kidney recipients had delayed graft function. The mean serum creatinine level at 3 months was 123 +/- 41 micromol/l. All pancreas recipients were insulin-free at 3 months. Primary graft nonfunction occurred in one liver recipient. Complete hepatic artery thrombosis occurred in six liver recipients during the first month; four of these patients had a risk factor for thrombosis. All but three of the heart recipients were in sinus rhythm on day 1, and 65% were extubated on day 1. Inotropic drugs were necessary during the first 72 h in 25% of heart recipients. Twelve-month patient and graft survival rates were, respectively, 100% and 96% (kidney), 100% and 89% (pancreas), 88% and 83% (liver), 77.5% (heart) and 67% (heart-lung). These results suggest that Celsior, a ready-to-use solution, is safe and effective for multiple organ procurement and preservation.
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Affiliation(s)
- Georges Karam
- Pôle Néphrologie-Urologie-Transplantation, Hôtel Dieu, Centre Hospitalier Universitaire de Nantes, Nantes, France
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Fehrenbach H, Tews S, Fehrenbach A, Ochs M, Wittwer T, Wahlers T, Richter J. Improved lung preservation relates to an increase in tubular myelin-associated surfactant protein A. Respir Res 2005; 6:60. [PMID: 15969762 PMCID: PMC1187923 DOI: 10.1186/1465-9921-6-60] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Accepted: 06/21/2005] [Indexed: 12/15/2022] Open
Abstract
Background Declining levels of surfactant protein A (SP-A) after lung transplantation are suggested to indicate progression of ischemia/reperfusion (IR) injury. We hypothesized that the previously described preservation-dependent improvement of alveolar surfactant integrity after IR was associated with alterations in intraalveolar SP-A levels. Methods Using immuno electron microscopy and design-based stereology, amount and distribution of SP-A, and of intracellular surfactant phospholipids (lamellar bodies) as well as infiltration by polymorphonuclear leukocytes (PMNs) and alveolar macrophages were evaluated in rat lungs after IR and preservation with EuroCollins or Celsior. Results After IR, labelling of tubular myelin for intraalveolar SP-A was significantly increased. In lungs preserved with EuroCollins, the total amount of intracellular surfactant phospholipid was reduced, and infiltration by PMNs and alveolar macrophages was significantly increased. With Celsior no changes in infiltration or intracellular surfactant phospholipid amount occurred. Here, an increase in the number of lamellar bodies per cell was associated with a shift towards smaller lamellar bodies. This accounts for preservation-dependent changes in the balance between surfactant phospholipid secretion and synthesis as well as in inflammatory cell infiltration. Conclusion We suggest that enhanced release of surfactant phospholipids and SP-A represents an early protective response that compensates in part for the inactivation of intraalveolar surfactant in the early phase of IR injury. This beneficial effect can be supported by adequate lung preservation, as e.g. with Celsior, maintaining surfactant integrity and reducing inflammation, either directly (via antioxidants) or indirectly (via improved surfactant integrity).
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Affiliation(s)
- Heinz Fehrenbach
- Clinical Research Group "Chronic Airway Diseases", Department of Internal Medicine (Respiratory Medicine), Philipps-University, Baldingerstrasse, D-35043 Marburg, Germany
| | - Sebastian Tews
- Division of Electron Microscopy, Centre of Anatomy, University of Göttingen, Kreuzbergring 36, D-37075 Göttingen, Germany
| | - Antonia Fehrenbach
- Division of Electron Microscopy, Centre of Anatomy, University of Göttingen, Kreuzbergring 36, D-37075 Göttingen, Germany
- Clinical Research Group "Chronic Airway Diseases", Department of Internal Medicine (Respiratory Medicine), Philipps-University, Baldingerstrasse, D-35043 Marburg, Germany
| | - Matthias Ochs
- Division of Electron Microscopy, Centre of Anatomy, University of Göttingen, Kreuzbergring 36, D-37075 Göttingen, Germany
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, CH-3000 Bern 9, Switzerland
| | - Thorsten Wittwer
- Department of Cardiothoracic and Vascular Surgery, Friedrich Schiller University Jena, Bachstrasse 18, D-07740 Jena, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic and Vascular Surgery, Friedrich Schiller University Jena, Bachstrasse 18, D-07740 Jena, Germany
| | - Joachim Richter
- Division of Electron Microscopy, Centre of Anatomy, University of Göttingen, Kreuzbergring 36, D-37075 Göttingen, Germany
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Jayle C, Corbi P, Eugene M, Carretier M, Hebrard W, Menet E, Hauet T. Beneficial effect of polyethylene glycol in lung preservation: early evaluation by proton nuclear magnetic resonance spectroscopy. Ann Thorac Surg 2003; 76:896-902. [PMID: 12963225 DOI: 10.1016/s0003-4975(03)00662-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Proton nuclear magnetic resonance spectroscopy can be used to measure organic molecules in biological fluids. In this study, proton nuclear magnetic resonance spectroscopy of bronchoalveolar lavage was assessed to detect cellular damage in lung transplants. Also we evaluated a polyethylene glycol solution in lung preservation. METHODS An isolated perfused and working pig lung was used to assess initial pulmonary function after in situ cold flush and cold storage for 6 hours in three preservation solutions: (1) Euro-Collins solution, (2) University of Wisconsin solution, and (3) low potassium solution with polyethylene glycol (PEG). Pulmonary vascular resistance and partial pressure of arterial oxygen were measured during reperfusion. Bronchoalveolar lavage was studied by proton nuclear magnetic resonance spectroscopy and a histologic study of the lungs was done at the harvest after ischemia and after reperfusion. RESULTS Partial pressure of arterial oxygen and pulmonary vascular resistance were significantly better in PEG compared with Euro-Collins solution (p = 0.011). Interstitial edema was significantly higher in Euro-Collins solution (2.4 +/- 0.24; p = 0.02) and University of Wisconsin solution (2.7 +/- 0.20; p = 0.0003) than PEG (2 +/- 0.16). Mitochondria scale was better in PEG (8.1 +/- 0.46) than in Euro-Collins solution (6.2 +/- 0.37; p = 0.0001) or University of Wisconsin solution (5.6 +/- 1.36; p = 0.0046). In bronchoalveolar lavage proton nuclear magnetic resonance spectroscopy spectra, lactate, pyruvate, citrate, and acetate were only detected after reperfusion, with a significantly reduced production of acetate in PEG. Pyruvate was reduced at the limit of significance in PEG versus University of Wisconsin solution. CONCLUSIONS Proton nuclear magnetic resonance spectroscopy seems to be a simple and suitable method for assessment of early injury to the lung transplant. In this experimental study, PEG preserved the lung better than University of Wisconsin solution and Euro-Collins solution in both the proton nuclear magnetic resonance spectroscopy study as well as the physiologic study.
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de Perrot M, Liu M, Waddell TK, Keshavjee S. Ischemia-reperfusion-induced lung injury. Am J Respir Crit Care Med 2003; 167:490-511. [PMID: 12588712 DOI: 10.1164/rccm.200207-670so] [Citation(s) in RCA: 664] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Ischemia-reperfusion-induced lung injury is characterized by nonspecific alveolar damage, lung edema, and hypoxemia occurring within 72 hours after lung transplantation. The most severe form may lead to primary graft failure and remains a significant cause of morbidity and mortality after lung transplantation. Over the past decade, better understanding of the mechanisms of ischemia-reperfusion injury, improvements in the technique of lung preservation, and the development of a new preservation solution specifically for the lung have been associated with a reduction in the incidence of primary graft failure from approximately 30 to 15% or less. Several strategies have also been introduced into clinical practice for the prevention and treatment of ischemia-reperfusion-induced lung injury with various degrees of success. However, only three randomized, double-blinded, placebo-controlled trials on ischemia-reperfusion-induced lung injury have been reported in the literature. In the future, the development of new agents and their application in prospective clinical trials are to be expected to prevent the occurrence of this potentially devastating complication and to further improve the success of lung transplantation.
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Affiliation(s)
- Marc de Perrot
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Abrahamse STL, Dinant S, Pfaffendorf M, van Gulik TM. In vitro function of porcine carotid arteries preserved in UW, HTK and Celsior solutions. Fundam Clin Pharmacol 2002; 16:503-11. [PMID: 12685509 DOI: 10.1046/j.1472-8206.2002.00112.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We compared the efficacy of histidine-tryptophan-ketoglutarate (HTK) and University of Wisconsin (UW) solution with Celsior solution using hypothermically-preserved porcine carotid arteries and studied the importance of different components of these solutions by preserving carotid arteries in modified HTK solutions. Excised carotid arteries were stored at 4 degrees C in 0.9% (w/v) NaCl, UW, HTK, Celsior, or a modified HTK solution for up to 14 days. Preservation-induced changes in smooth muscle cell and endothelial cell function were determined using an organ bath for isometric tension recording. Short-term preservation (1-3 days) in UW, HTK and Celsior did not significantly alter contractile and relaxation responses of arterial segments when compared to freshly-excised segments, but significantly impaired these responses in arterial segments stored in 0.9% (w/v) NaCl solution. Long-term hypothermic preservation of arterial segments (7 and 14 days) in 0.9% (w/v) NaCl and HTK solution almost completely abolished all responses, but only slightly reduced the responses of arterial segments stored in UW solution. Intermediate results were obtained for Celsior. Modifying HTK by replacement of chloride for sulfate and phosphate resulted in improved contractile and relaxation responses after long-term preservation. With respect to smooth muscle and endothelial function, UW is superior to HTK and Celsior and the absence of chloride or presence of sulfate and phosphate plays a relevant role in this in vitro model of hypothermic preservation of porcine carotid arteries.
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Affiliation(s)
- S T L Abrahamse
- Department of Surgery (Surgical Laboratory), Academic Medical Center, The University of Amsterdam, The Netherlands
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Baron O, Fabre S, Haloun A, Treilhaud M, al Habasch O, Duveau D, Michaud JL, Despins P. Retrospective clinical comparison of Celsior solution to modified blood Wallwork solution in lung transplantation for cystic fibrosis. Prog Transplant 2002. [PMID: 12371042 DOI: 10.7182/prtr.12.3.g2g0678241r53637] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare the preservative effects of Celsior solution and modified blood Wallwork solution in lung transplantation. METHODS From 1989 to 2000, 44 lung transplantations for cystic fibrosis were performed: 26 grafts were preserved with modified blood Wallwork solution and 18 with Celsior solution. RESULTS Preoperative status of the 2 groups was similar. The ratio of arterial oxygen to fraction of inspired oxygen and the pulmonary vascular resistance on the first postoperative day did not differ significantly between the 2 groups. Early death was 4% (SD, 20%) in the Wallwork group versus 11% (SD, 32%) in the Celsior group (not significant). No death was related to graft failure. The forced expiratory volume in 1 second during the first month after transplantation was 63% (SD, 19%) in the Wallwork group versus 63% (SD, 16%) in the Celsior group (not significant). CONCLUSION Because the solution does not need to be prepared on site and does not require blood from the donor, Celsior seems better than Wallwork solution for preserving lung grafts.
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Affiliation(s)
- O Baron
- Thoracic Transplantation Unit, Cardiovascular Surgery Department, Laennec Hospital, Nantes, France
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16
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Ohwada S, Sunose Y, Aiba M, Tsutsumi H, Iwazaki S, Totsuka O, Matsumoto K, Takeyoshi I, Morishita Y. Advantages of Celsior solution in graft preservation from non-heart-beating donors in a canine liver transplantation model. J Surg Res 2002; 102:71-6. [PMID: 11796001 DOI: 10.1006/jsre.2001.6296] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The optimal method for preserving livers from non-heart-beating donors (NHBD) is still unknown. We compared the Celsior solution, a new extracellular-type, low-potassium, low-viscosity preservation solution, with the University of Wisconsin (UW) solution in a canine orthotopic liver transplantation from NHBD. MATERIALS AND METHODS Fourteen adult mongrel dogs, weighing 9 to 17 kg, were divided into two groups: the Celsior or the UW group (n = 7 each). The thoracic descending aorta and supradiaphragmatic inferior vena cava were cross-clamped for 20 min to induce warm ischemia as a NHBD model. The liver was flushed with the respective cold preservation solution and then stored at 4 degrees C for 4 h. The grafts were transplanted using the piggy-back technique under portal decompression by leaving the native right lobe as a temporary shunt. RESULTS The duration of liver flushing out (min) was shorter (P < 0.05), and the serum glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, lactate dehydrogenase, lactate, and alpha-glutathione S-transferase concentrations 2 and 6 h after reperfusion of the graft (RPF) were lower (P < 0.05) in the Celsior group than in the UW group. Hepatic tissue blood flow (HTBF) did not deteriorate as much (P < 0.05) in the Celsior group. The serum endothelin-1 level was lower (P < 0.05) in the Celsior group 2 h after RPF. Histopathology of liver specimens revealed portal congestion and hepatocyte necrosis with neutrophil infiltration in the UW group, while these findings were mild in the Celsior group. CONCLUSIONS The Celsior solution improves vascular endothelial injury in livers from NHBDs and may have advantages in graft flush and preservation of grafts from NHBDs.
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Affiliation(s)
- Susumu Ohwada
- Second Department of Surgery, Gunma University Faculty of Medicine, 3-39-15 Showa-Machi, Maebashi, 371-8511, Japan.
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17
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Thabut G, Vinatier I, Brugière O, Lesèche G, Loirat P, Bisson A, Marty J, Fournier M, Mal H. Influence of preservation solution on early graft failure in clinical lung transplantation. Am J Respir Crit Care Med 2001; 164:1204-8. [PMID: 11673210 DOI: 10.1164/ajrccm.164.7.2012135] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to assess the influence of preservation solution type and extra- or intracellular composition on the occurrence of early graft dysfunction after clinical lung transplantation. For 170 patients who underwent a single (n = 124) or bilateral (n = 46) lung transplantation in two centers in Paris between 1988 and 1999, the preservation technique applied to the donor lung was single-flush perfusion of the pulmonary artery with one of several solutions of intracellular (Euro-Collins, n = 61; University of Wisconsin, n = 24) or extracellular composition (Cambridge, n = 64; Celsior, n = 21). The early postoperative outcome of these patients was reviewed. Reimplantation edema occurred in 48% of all patients, and the overall 1-mo survival rate was 84%. No significant difference in the incidence of edema, duration of mechanical ventilation, and 1-mo survival rate was observed between the four groups or between intra- and extracellular groups. After adjustment for graft ischemic time by means of multivariate analysis, the use of extracellular preservation fluid was associated with a lower incidence of reimplantation edema without effect on 1-mo mortality. Graft ischemic time was associated with both edema occurrence and 1-mo survival rate (p = 0.02 and p = 0.01, respectively). We conclude that extracellular-type solutions are associated with better lung preservation than intracellular-type solutions in clinical transplantation.
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Affiliation(s)
- G Thabut
- Service de Pneumologie et Réanimation Respiratoire, Hôpital Beaujon, Clichy, France
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18
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Fehrenbach A, Wittwer T, Meyer D, von Vietinghoff S, Viehöver M, Fehrenbach H, Richter J, Wahlers T. Nitroglycerin alters alveolar type II cell ultrastructure after ischemia and reperfusion. J Heart Lung Transplant 2001; 20:876-88. [PMID: 11502410 DOI: 10.1016/s1053-2498(01)00275-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although administration of nitric oxide (NO) has been suggested to reduce pulmonary reimplantation response, concerns remain about cytotoxic side effects. METHODS Using light and electron microscopy, we examined the effects of the NO donor nitroglycerin (NTG) (0.1 mg/ml) as a supplement to the preservation solution Celsior on the structural integrity of rat lungs after extracorporeal ischemia (4 hours at 10 degrees C) and reperfusion (50 minutes) (IR). We performed evaluation in comparison with Celsior alone after IR using either standard antegrade perfusion through the pulmonary artery or retrograde perfusion through the left atrium as an alternative way to improve the preservation quality. Untreated, non-ischemic lungs served as controls (n = 5 per group). We recorded respiratory and hemodynamic parameters during reperfusion. Tissue collection using systematic uniform random sampling was representative for the whole organ and allowed stereologic quantification of structures. RESULTS After IR, histochemistry revealed no breaks in the alveolo-capillary barrier and we detected no alveolar flooding. Edema formed in the peribronchovascular cuffs, of which the volume fraction was increased (p =.008). Vasoconstriction of the smaller arteries accompanied antegrade flush, which occurred neither after administration of NTG nor after retrograde flush, as shown by immunostaining for alpha-smooth muscle actin. Treatment with NTG was associated with focal disintegration of Type II cells, which displayed edematous swelling of distinct cell compartments and lysis of mitochondria and cells. Nitroglycerin prevented alveolar collapse, which was increased in the other IR groups (p = 0.013). We observed alterations in intra-alveolar surfactant components. CONCLUSION These findings indicate pathologic effects of NTG treatment on alveolar epithelial integrity. Therefore, we suggest further critical evaluation of NTG/NO for therapeutic use in lung transplantation.
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Affiliation(s)
- A Fehrenbach
- Division of Electron Microscopy, Center of Anatomy, University of Göttingen, Göttingen, Germany.
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19
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Audet M, Alexandre E, Mustun A, David P, Chenard-Neu MP, Tiollier J, Jaeck D, Cinqualbre J, Wolf P, Boudjema K. Comparative evaluation of Celsior solution versus Viaspan in a pig liver transplantation model. Transplantation 2001; 71:1731-5. [PMID: 11455250 DOI: 10.1097/00007890-200106270-00005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In a pig liver transplantation model, we compared the effects of Celsior solution (CS), an extracellular preservation solution, with Viaspan (University of Wisconsin solution, UW) on graft function and animal survival. METHODS Pig livers were flushed with either CS or UW solution and cold-stored for 12 hr (group 1) or for 8 to 10 hr (group 2). Grafts were transplanted orthotopically. Intrahepatic reduced and oxidized glutathione and adenine nucleotides were evaluated 1 hr after reperfusion. Liver function of transplanted animals was monitored for up to 6 days by serum transaminases, total bilirubin, purine nucleoside phosphorylase, and prothrombin levels. RESULTS In group 1, all animals died within 24 hr after reperfusion regardless of the preservation solution used. In group 2, no significant difference was seen in survival between the CS (72%) and the UW (67%) groups 6 days after transplantation, and there were no statistically significant differences in the biochemical data. There were no differences in histological evaluation of the livers at the time of death or killing of the animals between the CS and UW groups. CONCLUSION Within the limits of this pilot study, CS is equivalent to UW in terms of graft function and animal survival.
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Affiliation(s)
- M Audet
- Service de Chirurgie Générale et de Transplantation, Hôpital de Hautepierre, 67098 Strasbourg, France.
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20
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Tsutsumi H, Oshima K, Mohara J, Takeyoshi I, Aizaki M, Tokumine M, Matsumoto K, Morishita Y. Cardiac transplantation following a 24-h preservation using a perfusion apparatus. J Surg Res 2001; 96:260-7. [PMID: 11266282 DOI: 10.1006/jsre.2001.6077] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND We developed a new apparatus for heart preservation and have already reported successful transplantation following 12 h of preservation using this apparatus. The efficacy of coronary perfusion with an oxygenated Celsior solution was investigated through transplantation following 24 h of preservation using the apparatus. MATERIALS AND METHODS After being harvested, grafts were preserved with a combination of immersion in a 4 degrees C Celsior solution and perfusion with an oxygenated Celsior solution using the apparatus in the coronary perfusion (CP) group and simply immersed in a 4 degrees C Celsior solution in the simple immersion(SI) group. beta-Adenosine triphosphate (beta-ATP), phosphocreatine (Pcr), and inorganic phosphate (P(i)) levels and myocardial pH (pH(i)) were measured immediately after the heart was excised and at 12 and 24 h after preservation. Following preservation, orthotopic transplantation was performed. Cardiac function was measured 2 h after weaning from cardiopulmonary bypass (CPB). RESULTS beta-ATP/P(i), Pcr/P(i), and pH(i) levels were significantly higher in the CP group than in the SI group at 12 and 24 h after preservation. Four of six animals in the CP group and two of six in the SI group were successfully weaned from CPB. The recovery rates of cardiac function were better in the CP group than in the SI group. CONCLUSION Twenty-four hours of heart preservation may be possible with a combination of immersion in a 4 degrees C Celsior solution and perfusion with an oxygenated Celsior solution using the perfusion apparatus.
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Affiliation(s)
- H Tsutsumi
- Second Department of Surgery, Gunma University School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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21
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Ohwada S, Sunose Y, Tsutsumi H, Iwazaki S, Aiba M, Kasahara M, Kawashima Y, Takeyoshi I, Matsumoto K, Morishita Y. Celsior is superior to UW for graft preservation from non-heart-beating donors in a canine liver transplantation model. Transplant Proc 2001; 33:922-3. [PMID: 11267130 DOI: 10.1016/s0041-1345(00)02270-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- S Ohwada
- Second Department of Surgery, Gunma University Faculty of Medicine, Maebashi, Japan
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22
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Tsutsumi H, Takeyoshi I, Oshima K, Mohara J, Aizaki M, Morishita Y. The Effect of Coronary Perfusion with an Oxygenated Celsior Solution on 12-hour Cardiac Preservation. Int J Angiol 2001; 10:15-19. [PMID: 11178780 DOI: 10.1007/bf01616337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Celsior is a new extracellular-type cardiac preservation solution. We recently developed an apparatus for preservation using low-pressure continuous coronary perfusion. The purpose of this study was to investigate the efficacy of coronary perfusion with an oxygenated Celsior solution using the new apparatus for prolonged cardiac preservation. Adult mongrel dogs weighing 9-13 kg were divided into two groups: the coronary perfusion group (CP; n = 5) and the simple immersion group (SI; n = 7). The coronary vascular beds were washed out with a 4 degrees C Celsior solution following cardiac arrest using the same solution, and their hearts were excised. In the CP group, the graft was immersed in a 4 degrees C Celsior solution and perfused with the same oxygenated solution. In the SI group, the graft was simply immersed in a 4 degrees C Celsior solution. beta-adenosine triphosphate (beta-ATP), phosphocreatine (Pcr), inorganic phosphate (Pi) levels and myocardial pH (pHi) were measured immediately after excising the heart, and at 3, 6, and 12 hours after preservation. beta-ATP, Pcr, and Pi values were expressed as a percentage of control values, which were measured immediately after excising the heart. beta-ATP/Pi and Pcr/Pi levels were significantly higher in the CP group than in the SI group at 6 and at 12 hours after preservation. The pHi levels during preservation were significantly higher in the CP group than in the SI group. Low-pressure hypothermic coronary perfusion with an oxygenated Celsior solution is effective for long-term heart preservation. </hea
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Affiliation(s)
- Hirofumi Tsutsumi
- Second Department of Surgery, Gunma University School of Medicine, Maebashi, Gunma, Japan
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23
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Kelly RF. Current strategies in lung preservation. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 2000; 136:427-40. [PMID: 11128744 DOI: 10.1067/mlc.2000.110906] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Current methods of lung preservation allow for effective, expeditious transplantation as a treatment for end-stage pulmonary disease. However, the utilization of hypothermia, hyperkalemia, and pulmonary artery distension as a single rapid flush for perfusion is less than ideal. All these interventions result in increased pulmonary vascular resistance and suboptimal preservation of lung function. The ability to preserve lungs for longer time intervals and with less risk of tissue injury would provide significant advantages. There would be a greater likelihood that rare size or blood types could find matches by enlarging the area of organ distribution. Optimal preservation would also improve the perioperative outcomes in regard to primary graft failure and subsequently reduce the later complication of chronic rejection and graft lung dysfunction. Finally, through a better understanding of the mechanisms of lung injury during preservation and by developing means to limit the injury, it would be possible to utilize organs from donors that at this time would not be considered optimal. This would increase the donor pool without compromising the recipient's outcome.
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Affiliation(s)
- R F Kelly
- Division of Cardiovascular and Thoracic Surgery, University of Minnesota, Minneapolis, USA
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24
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Fehrenbach A, Ochs M, Warnecke T, Wahlers T, Wittwer T, Schmiedl A, Elki S, Meyer D, Richter J, Fehrenbach H. Beneficial effect of lung preservation is related to ultrastructural integrity of tubular myelin after experimental ischemia and reperfusion. Am J Respir Crit Care Med 2000; 161:2058-65. [PMID: 10852788 DOI: 10.1164/ajrccm.161.6.9908014] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Ischemia/reperfusion (I/R) injury results in the impairment of surfactant activity. The hypothesis that the differences in lung preservation quality obtained by EuroCollins (EC) and Celsior (CE) solutions were related to surfactant alterations was tested. To avoid extensive structural damage and edema formation, which can secondarily affect the surfactant system, lungs were stored for a short ischemic period (2 h at 10 degrees C) and reperfused (50 min) in an isolated perfused rat lung model after preservation with either potassium-reduced (40 mmol) EC40 or with CE. Using a modified stereological approach ultrastructure, total amount and distribution of phospholipid membranes composing tubular myelin (tm) and small (s) and large (l) unilameliar vesicles (ul) were investigated in the organ in lungs fixed by vascular perfusion either in situ (controls) or after I/R (n = 5 per group). The total amount of intraalveolar surfactant was increased after I/R. However, a significant amount (p = 0.008) of tm was displaced into the alveolar lumen and showed wider meshes of the tm lattices than did the controls (p = 0.023) where almost all tm was epithelial. In lungs preserved with EC40, epithelial tm was significantly reduced (p = 0.018), resulting in a higher ratio (p = 0.034) of surface-inactive small ul (0.05 to 0.3 microm) to surface-active epithelial tm. In the CE group approximately 50% of the total tm pool was epithelial. This was accompanied by higher parenchymal air space and improved functional parameters. Epithelial and endothelial cell-specific immunostaining did not reveal any gross damage of the blood-gas barrier. In summary, improved lung function during reperfusion was associated with beneficial effects of lung preservation on tm integrity after I/R. These observations suggest that preservation solutions ameliorate events leading to surfactant disturbance even before extensive lung injury is manifested.
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Affiliation(s)
- A Fehrenbach
- Division of Electron Microscopy, Center of Anatomy, University of Göttingen, Göttingen, Germany.
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