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Kraft CJ, Namsrai BE, Tobolt D, Etheridge ML, Finger EB, Bischof JC. CPA toxicity screening of cryoprotective solutions in rat hearts. Cryobiology 2024; 114:104842. [PMID: 38158172 DOI: 10.1016/j.cryobiol.2023.104842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/21/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
In clinical practice, donor hearts are transported on ice prior to transplant and discarded if cold ischemia time exceeds ∼5 h. Methods to extend these preservation times are critically needed, and ideally, this storage time would extend indefinitely, enabling improved donor-to-patient matching, organ utilization, and immune tolerance induction protocols. Previously, we demonstrated successful vitrification and rewarming of whole rat hearts without ice formation by perfusion-loading a cryoprotective agent (CPA) solution prior to vitrification. However, these hearts did not recover any beating even in controls with CPA loading/unloading alone, which points to the chemical toxicity of the cryoprotective solution (VS55 in Euro-Collins carrier solution) as the likely culprit. To address this, we compared the toxicity of another established CPA cocktail (VEG) to VS55 using ex situ rat heart perfusion. The CPA exposure time was 150 min, and the normothermic assessment time was 60 min. Using Celsior as the carrier, we observed partial recovery of function (atria-only beating) for both VS55 and VEG. Upon further analysis, we found that the VEG CPA cocktail resulted in 50 % lower LDH release than VS55 (N = 4, p = 0.017), suggesting VEG has lower toxicity than VS55. Celsior was a better carrier solution than alternatives such as UW, as CPA + Celsior-treated hearts spent less time in cardiac arrest (N = 4, p = 0.029). While we showed substantial improvement in cardiac function after exposure to vitrifiable concentrations of CPA by improving both the CPA and carrier solution formulation, further improvements will be required before we achieve healthy cryopreserved organs for transplant.
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Affiliation(s)
- Casey J Kraft
- Department of Biomedical Engineering, University of Minnesota, USA
| | | | - Diane Tobolt
- Department of Surgery, University of Minnesota, USA
| | | | - Erik B Finger
- Department of Surgery, University of Minnesota, USA.
| | - John C Bischof
- Department of Biomedical Engineering, University of Minnesota, USA; Department of Mechanical Engineering, University of Minnesota, USA; Institute for Engineering in Medicine, University of Minnesota, USA.
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2
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Gerosa G, Zanatta P, Angelini A, Fedrigo M, Bianco R, Pittarello D, Lena T, Pepe A, Toscano G, Zanella F, Feltrin G, Pradegan N, Tarzia V. Overcoming the Boundaries of Heart Warm Ischemia in Donation After Circulatory Death: The Padua Case. ASAIO J 2024:00002480-990000000-00402. [PMID: 38334806 DOI: 10.1097/mat.0000000000002141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
A 45 year old male obese patient with a previous history of repaired congenital heart disease developed worsening heart failure making heart transplantation listing mandatory. Unfortunately, due to his anthropometric measures, the search for a suitable brain-dead donor was unsuccessful. For this reason, he accepted to be enrolled in the controlled donation after circulatory death (cDCD) program. According to the Italian Law regulating death declaration after cardiac arrest (no-touch period of 20 minutes-one of the longest in the world), we faced a 34 minute cardiac asystole, after which the heart was recovered through a thoraco-abdominal normothermic regional perfusion excluding the epiaortic vessels. The heart was then preserved by means of cold static storage. Heart transplantation was performed successfully without any signs of primary graft failure. Postoperative endomyocardial biopsies were negative for acute cellular and antibody-mediated rejection. Furthermore, echocardiographic and cardiac magnetic resonance evaluation of the heart did not show any functional abnormalities. The patient was discharged on post-operative day (POD) #39 in good clinical conditions.
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Affiliation(s)
- Gino Gerosa
- From the Cardiac Surgery Unit, Cardio-Thoraco-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Paolo Zanatta
- Department of Critical Care, Anesthesiology and Intensive Care Unit, Ca' Foncello Hospital, Treviso, Italy
| | - Annalisa Angelini
- Cardiovascular Pathology, Cardio-Thoraco-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Marny Fedrigo
- Cardiovascular Pathology, Cardio-Thoraco-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Roberto Bianco
- From the Cardiac Surgery Unit, Cardio-Thoraco-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Demetrio Pittarello
- Cardiac Surgery Anesthesiology and Intensive Care Unit, Cardio-Thoraco-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Tea Lena
- From the Cardiac Surgery Unit, Cardio-Thoraco-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Alessia Pepe
- Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy; and
| | - Giuseppe Toscano
- From the Cardiac Surgery Unit, Cardio-Thoraco-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Fabio Zanella
- From the Cardiac Surgery Unit, Cardio-Thoraco-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Giuseppe Feltrin
- Regional Health Department, Regional Transplant Center, Veneto Region, Italy
| | - Nicola Pradegan
- From the Cardiac Surgery Unit, Cardio-Thoraco-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Vincenzo Tarzia
- From the Cardiac Surgery Unit, Cardio-Thoraco-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
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3
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Nielsen WH, Gustafsson F, Olsen PS, Hansen PB, Rossing K, Lilleør NB, Møller-Sørensen PH, Møller CH. Short-term outcomes after heart transplantation using donor hearts preserved with ex vivo perfusion. SCAND CARDIOVASC J 2023; 57:2267804. [PMID: 37822186 DOI: 10.1080/14017431.2023.2267804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/01/2023] [Indexed: 10/13/2023]
Abstract
The standard Conventional Cold Storage (CCS) during heart transplantation procurement is associated with time-dependent ischemic injury to the graft, which is a significant independent risk factor for post-transplant early morbidity and mortality - especially when cold ischemic time exceeds four hours. Since 2018, Rigshospitalet (Copenhagen, Denmark) has been utilising ex vivo perfusion (Organ Care System, OCS) in selected cases. The objective of this study was to compare the short-term clinical outcomes of patients transplanted with OCS compared to CCS. Methods: This retrospective single-centre study was based on consecutive patients undergoing a heart transplant between January 2018 and April 2021. Patients were selected for the OCS group when the cold ischemic time was expected to exceed four hours. The primary outcome measure was six-month event-free survival. Results: In total, 48 patients were included in the study; nine were transplanted with an OCS heart. The two groups had no significant differences in baseline characteristics. Six-month event-free survival was 77.8% [95% CI: 54.9-100%] in the OCS group and 79.5% [95% CI: 67.8-93.2%] in the CCS group (p = 0.91). While the OCS group had a median out-of-body time that was 183 min longer (p < 0.0001), the cold ischemic time was reduced by 51 min (p = 0.007). Conclusion: In a Scandinavian setting, our data confirms that utilising OCS in heart procurement allows for a longer out-of-body time and a reduced cold ischemic time without negatively affecting safety or early post-transplant outcomes.
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Affiliation(s)
- William Herrik Nielsen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Skov Olsen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Bo Hansen
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kasper Rossing
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Nikolaj Bang Lilleør
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Hasse Møller-Sørensen
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Holdflod Møller
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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4
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Kounatidis D, Brozou V, Anagnostopoulos D, Pantos C, Lourbopoulos A, Mourouzis I. Donor Heart Preservation: Current Knowledge and the New Era of Machine Perfusion. Int J Mol Sci 2023; 24:16693. [PMID: 38069017 PMCID: PMC10706714 DOI: 10.3390/ijms242316693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023] Open
Abstract
Heart transplantation remains the conventional treatment in end-stage heart failure, with static cold storage (SCS) being the standard technique used for donor preservation. Nevertheless, prolonged cold ischemic storage is associated with the increased risk of early graft dysfunction attributed to residual ischemia, reperfusion, and rewarming damage. In addition, the demand for the use of marginal grafts requires the development of new methods for organ preservation and repair. In this review, we focus on current knowledge and novel methods of donor preservation in heart transplantation. Hypothermic or normothermic machine perfusion may be a promising novel method of donor preservation based on the administration of cardioprotective agents. Machine perfusion seems to be comparable to cold cardioplegia regarding donor preservation and allows potential repair treatments to be employed and the assessment of graft function before implantation. It is also a promising platform for using marginal organs and increasing donor pool. New pharmacological cardiac repair treatments, as well as cardioprotective interventions have emerged and could allow for the optimization of this modality, making it more practical and cost-effective for the real world of transplantation. Recently, the use of triiodothyronine during normothermic perfusion has shown a favorable profile on cardiac function and microvascular dysfunction, likely by suppressing pro-apoptotic signaling and increasing the expression of cardioprotective molecules.
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Affiliation(s)
| | | | | | | | | | - Iordanis Mourouzis
- Department of Pharmacology, National and Kapodistrian University of Athens, 11527 Athens, Greece; (D.K.); (V.B.); (D.A.); (C.P.); (A.L.)
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5
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Peled Y, Kittleson MM. Two negatives make a positive: Maximizing heart procurement in adult congenital heart disease. J Heart Lung Transplant 2023; 42:1489-1492. [PMID: 37579830 DOI: 10.1016/j.healun.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/03/2023] [Accepted: 08/05/2023] [Indexed: 08/16/2023] Open
Affiliation(s)
- Yael Peled
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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6
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Pradegan N, Gallo M, Fabozzo A, Toscano G, Tarzia V, Gerosa G. Nonischemic Donor Heart Preservation: New Milestone in Heart Transplantation History. ASAIO J 2023; 69:725-733. [PMID: 37319037 DOI: 10.1097/mat.0000000000002001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
Heart transplantation is considered the gold standard for the treatment of advanced end-stage heart failure. However, standard donors after brain death are decreasing, whereas patients on the heart transplant waitlist are constantly rising. The introduction of the ex vivo machine perfusion device has been a turning point; in fact, these systems are able to significantly reduce ischemic times and have a potential effect on ischemia-related damage reduction. From a clinical standpoint, these machines show emerging results in terms of heart donor pool expansion, making marginal donors and donor grafts after circulatory death suitable for donation. This article aims to review mechanisms and preclinical and clinical outcomes of currently available ex vivo perfusion systems, and to explore the future fields of application of these technologies.
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Affiliation(s)
- Nicola Pradegan
- From the Cardiac Surgery Unit, Heart Transplantation Program, Cardiac, Thoracic, Vascular Sciences and Public Health Department, Padova University Hospital, Padova, Italy
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7
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Okoh AK, Fugar S, Dodoo S, Selevany M, Al-Obaidi N, Ozturk E, Singh S, Tayal R, Lee LY, Russo MJ, Camacho M. Derivation and validation of the bridge to transplantation with left ventricular assist device score for 1 year mortality after heart transplantation. The BTT-LVAD score. Int J Artif Organs 2022; 45:470-477. [PMID: 35365063 PMCID: PMC10024971 DOI: 10.1177/03913988221082690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To derive and validate a risk score that accurately predicts 1-year mortality after heart transplantation (HT) in patients bridged to transplant (BTT) with a left ventricular assist device (LVAD). METHODS The UNOS database was queried to identify patients BTT with an LVAD between 2008 and 2018. Patients with ⩾1-year follow up were randomly divided into derivation (70%) and validation (30%) cohorts. The primary endpoint was 1-year mortality. A simple additive risk score was developed based on the odds of 1-year mortality after HT. Risk groups were created, and survival was estimated and compared. RESULTS A total of 7759 patients were randomly assigned to derivation (n = 5431) and validation (n = 2328) cohorts. One-year post-transplant mortality was 9.8% (n = 760). A 33-point scoring was created from six recipient variables and two donor variables. Risk groups were classified as low (0-5), intermediate (6-10), and high (>10). In the validation cohort, the predicted 1-year mortality was significantly higher in the high-risk group than the intermediate and low-risk groups, 14.7% versus 9% versus 6.1% respectively (log-rank test: p < 0.0001). CONCLUSION The BTT-LVAD Score can serve as a clinical decision tool to guide therapeutic decisions in advanced heart failure patients.
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Affiliation(s)
- Alexis K Okoh
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Setri Fugar
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Sheriff Dodoo
- Department of Medicine, Piedmont Newnan Hospital, Newnan, GA, USA
| | - Mariam Selevany
- Cardiovascular Research Unit, RWJBarnabas Health, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Nawar Al-Obaidi
- Cardiovascular Research Unit, RWJBarnabas Health, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Ebru Ozturk
- Division of Biostatistics, Hacettepe University School of Medicine, Ankara, Turkey
| | - Swaiman Singh
- Cardiovascular Research Unit, RWJBarnabas Health, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Rajiv Tayal
- Cardiovascular Research Unit, RWJBarnabas Health, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Leonard Y Lee
- Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Mark J Russo
- Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Margarita Camacho
- Cardiovascular Research Unit, RWJBarnabas Health, Newark Beth Israel Medical Center, Newark, NJ, USA
- Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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8
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Pinnelas R, Kobashigawa JA. Ex vivo normothermic perfusion in heart transplantation: a review of the TransMedics ® Organ Care System. Future Cardiol 2021; 18:5-15. [PMID: 34503344 DOI: 10.2217/fca-2021-0030] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Cardiac transplantation is the gold standard for treatment for select patients with end-stage heart failure, yet donor supply is limited. Ex vivo machine perfusion is an emerging technology capable of safely preserving organs and expanding the viable donor pool. The TransMedics® Organ Care System™ is an investigational device which mimics physiologic conditions while maintaining the heart in a warm, beating state rather than cold storage. The use of Organ Care System allows increased opportunities for using organs from marginal donors, distant procurement sites, donation after cardiac death, and in recipients with complex anatomy. In the future, bioengineering technologies including use of mesenchymal stem cells, viral vector delivery of gene therapy, and alternate devices may further broaden the field of ex vivo machine perfusion.
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9
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Cullen PP, Tsui SS, Caplice NM, Hinchion JA. A state-of-the-art review of the current role of cardioprotective techniques in cardiac transplantation. Interact Cardiovasc Thorac Surg 2021; 32:683-694. [PMID: 33971665 DOI: 10.1093/icvts/ivaa333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/24/2020] [Accepted: 12/06/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The use of 'extended criteria' donor hearts and reconditioned hearts from donation after circulatory death has corresponded with an increase in primary graft dysfunction, with ischaemia-reperfusion injury being a major contributing factor in its pathogenesis. Limiting ischaemia-reperfusion injury through optimising donor heart preservation may significantly improve outcomes. We sought to review the literature to evaluate the evidence for this. METHODS A review of the published literature was performed to assess the potential impact of organ preservation optimisation on cardiac transplantation outcomes. RESULTS Ischaemia-reperfusion injury is a major factor in myocardial injury during transplantation with multiple potential therapeutic targets. Innate survival pathways have been identified, which can be mimicked with pharmacological conditioning. Although incompletely understood, discoveries in this domain have yielded extremely encouraging results with one of the most exciting prospects being the synergistic effect of selected agents. Ex situ heart perfusion is an additional promising adjunct. CONCLUSIONS Cardiac transplantation presents a unique opportunity to perfuse the whole heart before, or immediately after, the onset of ischaemia, thus maximising the potential for global cardioprotection while limiting possible systemic side effects. While clinical translation in the setting of myocardial infarction has often been disappointing, cardiac transplantation may afford the opportunity for cardioprotection to finally deliver on its preclinical promise.
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Affiliation(s)
- Paul P Cullen
- Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
| | - Steven S Tsui
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Noel M Caplice
- Centre for Research in Vascular Biology, Biosciences Institute, University College Cork, Cork, Ireland
| | - John A Hinchion
- Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
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10
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Da Silveira Cavalcante L, Tessier SN. Zebrafish as a New Tool in Heart Preservation Research. J Cardiovasc Dev Dis 2021; 8:39. [PMID: 33917701 PMCID: PMC8068018 DOI: 10.3390/jcdd8040039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 12/25/2022] Open
Abstract
Heart transplantation became a reality at the end of the 1960s as a life-saving option for patients with end-stage heart failure. Static cold storage (SCS) at 4-6 °C has remained the standard for heart preservation for decades. However, SCS only allows for short-term storage that precludes optimal matching programs, requires emergency surgeries, and results in the unnecessary discard of organs. Among the alternatives seeking to extend ex vivo lifespan and mitigate the shortage of organs are sub-zero or machine perfusion modalities. Sub-zero approaches aim to prolong cold ischemia tolerance by deepening metabolic stasis, while machine perfusion aims to support metabolism through the continuous delivery of oxygen and nutrients. Each of these approaches hold promise; however, complex barriers must be overcome before their potential can be fully realized. We suggest that one barrier facing all experimental efforts to extend ex vivo lifespan are limited research tools. Mammalian models are usually the first choice due to translational aspects, yet experimentation can be restricted by expertise, time, and resources. Instead, there are instances when smaller vertebrate models, like the zebrafish, could fill critical experimental gaps in the field. Taken together, this review provides a summary of the current gold standard for heart preservation as well as new technologies in ex vivo lifespan extension. Furthermore, we describe how existing tools in zebrafish research, including isolated organ, cell specific and functional assays, as well as molecular tools, could complement and elevate heart preservation research.
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Affiliation(s)
- Luciana Da Silveira Cavalcante
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 2114, USA;
- Shriners Hospitals for Children, Boston, MA 2114, USA
| | - Shannon N. Tessier
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 2114, USA;
- Shriners Hospitals for Children, Boston, MA 2114, USA
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11
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Zheng H, Su Y, Zhu C, Quan D, Skaro AI, McAlister V, Lacefield JC, Jiang J, Xue P, Wang Y, Zheng X. An Addition of U0126 Protecting Heart Grafts From Prolonged Cold Ischemia-Reperfusion Injury in Heart Transplantation: A New Preservation Strategy. Transplantation 2021; 105:308-317. [PMID: 32776778 DOI: 10.1097/tp.0000000000003402] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Ischemia-reperfusion injury (IRI) is the major cause of primary graft dysfunction in organ transplantation. The mitogen-activated protein kinase/extracellular signal-regulated kinase (ERK) signaling pathway plays a crucial role in cell physiological and pathological processes including IRI. This study aims to investigate whether inhibition of ERK signaling with U0126 can prevent prolonged cold IRI in heart transplantation. METHODS Rat cardiac cell line H9c2 cells were treated with U0126 before exposure to hypothermic hypoxia/reoxygenation (H/R) conditions. The effect of U0126 on H9c2 cells in response to H/R stress was determined by measuring cell death, reactive oxygen species production, mitochondrial membrane potential, and ERK signaling activation. Mouse syngeneic heterotopic heart transplantation was conducted, where a donor heart was preserved in the University of Wisconsin (UW) solution supplemented with U0126 for 24 hours at 4°C before transplantation. Heart graft function, histopathologic changes, apoptosis, and fibrosis were measured to assess IRI. RESULTS Phosphorylated ERK was increased in both in vitro H/R-injured H9c2 cells and in vivo heart grafts with IRI. Pretreatment with U0126 inhibited ERK phosphorylation and prevented H9c2 cells from cell death, reactive oxygen species generation, and mitochondrial membrane potential loss in response to H/R. Preservation of donor hearts with U0126-supplemented solution improved graft function and reduced IRI by reductions in cell apoptosis/death, neutrophil infiltration, and fibrosis of the graft. CONCLUSIONS Addition of U0126 to UW solution reduces ERK signal activation and attenuates prolonged cold IRI in a heart transplantation model. ERK inhibition with U0126 may be a useful strategy to minimize IRI in organ transplantation.
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Affiliation(s)
- Hao Zheng
- Department of Pathology and Laboratory Medicine, Western University, London, ON, Canada
- College of Life Science, Wuhan University, Wuhan, China
| | - Yale Su
- Department of Pathology and Laboratory Medicine, Western University, London, ON, Canada
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Cuilin Zhu
- Department of Pathology and Laboratory Medicine, Western University, London, ON, Canada
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Douglas Quan
- Department of Surgery, Western University, London, ON, Canada
- Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - Anton I Skaro
- Department of Surgery, Western University, London, ON, Canada
- Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - Vivian McAlister
- Department of Surgery, Western University, London, ON, Canada
- Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - James C Lacefield
- Department of Electrical and Computer Engineering, Western University, London, ON, Canada
- Department of Medical Biophysics, Western University, London, ON, Canada
- Department of Oncology, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Jifu Jiang
- Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - Peng Xue
- College of Life Science, Wuhan University, Wuhan, China
| | - Yefu Wang
- Department of Pathology and Laboratory Medicine, Western University, London, ON, Canada
| | - Xiufen Zheng
- Department of Pathology and Laboratory Medicine, Western University, London, ON, Canada
- Department of Surgery, Western University, London, ON, Canada
- Department of Surgery, London Health Sciences Centre, London, ON, Canada
- Department of Oncology, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
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12
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Wang L, MacGowan GA, Ali S, Dark JH. Ex situ heart perfusion: The past, the present, and the future. J Heart Lung Transplant 2020; 40:69-86. [PMID: 33162304 DOI: 10.1016/j.healun.2020.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 01/06/2023] Open
Abstract
Despite the advancements in medical treatment, mechanical support, and stem cell therapy, heart transplantation remains the most effective treatment for selected patients with advanced heart failure. However, with an increase in heart failure prevalence worldwide, the gap between donor hearts and patients on the transplant waiting list keeps widening. Ex situ machine perfusion has played a key role in augmenting heart transplant activities in recent years by enabling the usage of donation after circulatory death hearts, allowing longer interval between procurement and implantation, and permitting the safe use of some extended-criteria donation after brainstem death hearts. This exciting field is at a hinge point, with 1 commercially available heart perfusion machine, which has been used in hundreds of heart transplantations, and a number of devices being tested in the pre-clinical and Phase 1 clinical trial stage. However, no consensus has been reached over the optimal preservation temperature, perfusate composition, and perfusion parameters. In addition, there is a lack of objective measurement for allograft quality and viability. This review aims to comprehensively summarize the lessons about ex situ heart perfusion as a platform to preserve, assess, and repair donor hearts, which we have learned from the pre-clinical studies and clinical applications, and explore its exciting potential of revolutionizing heart transplantation.
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Affiliation(s)
- Lu Wang
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Guy A MacGowan
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom; Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Simi Ali
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John H Dark
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
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13
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Ribeiro RVP, Friedrich JO, Ouzounian M, Yau T, Lee J, Yanagawa B. Supplemental Cardioplegia During Donor Heart Implantation: A Systematic Review and Meta-Analysis. Ann Thorac Surg 2020; 110:545-552. [PMID: 31972127 DOI: 10.1016/j.athoracsur.2019.10.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 10/16/2019] [Accepted: 10/21/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND The optimal donor heart preservation and management strategy during heart transplantation remains controversial. We report the results of a systematic review and meta-analysis of the effect of supplemental cardioplegia administration during donor heart implant for transplantation. METHODS We searched MEDLINE and Embase databases until February 2019 for studies comparing patients who received transplants with the donor heart given supplemental cardioplegia or not. Data were extracted by 2 independent investigators. The main outcomes were early morbidity and mortality. RESULTS Included were 7 retrospective observational studies (4 comparing to historical controls) and 3 randomized controlled trials enrolling 1125 patients. Supplemental cardioplegia included crystalloid and blood cardioplegia given continuous retrograde or as terminal "hot shots." Supplemental cardioplegia was associated with improved early mortality (risk ratio [RR], 0.55; 95% confidence interval [CI], 0.35-0.87; P < .01), greater rates of spontaneous return of sinus rhythm (RR, 2.62; 95% CI, 1.50-4.56; P < .01), shorter intensive care stay (mean difference, -3.4 days; 95% CI, -5.1 to -1.6; P < .01), and lower incidence of ischemic changes seen on endomyocardial biopsy specimens (RR, 0.49; 95% CI, 0.35-0.69; P < .01) compared with controls. Midterm mortality was not different between groups (incident rate ratio, 0.80; 95% CI, 0.51-1.26; P = .34). CONCLUSIONS Administration of supplemental cardioplegia may be associated with a reduction in organ ischemic injury and shorter intensive care stay as well as improvement in early survival after transplantation. This strategy may be a simple and cost-effective adjunct to improve outcomes of heart transplantation, especially in an era of increasing use of marginal donor organs. Further investigation will be needed to confirm the findings of this hypothesis-generating study.
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Affiliation(s)
- Roberto V P Ribeiro
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Critical Care and Medicine Departments and Li Ka Shing Knowledge Institute, St. Michael's Hospital, and Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Terrance Yau
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Lee
- Division of Cardiovascular Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiovascular Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.
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New Strategies to Expand and Optimize Heart Donor Pool: Ex Vivo Heart Perfusion and Donation After Circulatory Death: A Review of Current Research and Future Trends. Anesth Analg 2019; 128:406-413. [PMID: 30531220 DOI: 10.1213/ane.0000000000003919] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Heart transplantation remains the definitive management for end-stage heart failure refractory to medical therapy. While heart transplantation cases are increasing annually worldwide, there remains a deficiency in organ availability with significant patient mortality while on the waiting list. Attempts have therefore been made to expand the donor pool and improve access to available organs by recruiting donors who may not satisfy the standard criteria for organ donation because of donor pathology, anticipated organ ischemic time, or donation after circulatory death. "Ex vivo" heart perfusion (EVHP) is an emerging technique for the procurement of heart allografts. This technique provides mechanically supported warm circulation to a beating heart once removed from the donor and before implantation into the recipient. EVHP can be sustained for several hours, facilitate extended travel time, and enable administration of pharmacological agents to optimize cardiac recovery and function, as well as allow assessment of allograft function before implantation. In this article, we review recent advances in expanding the donor pool for cardiac transplantation. Current limitations of conventional donor criteria are outlined, including the determinants of organ suitability and assessment, involving transplantation of donation after circulatory death hearts, extended criteria donors, and EVHP-associated assessment, optimization, and transportation. Finally, ongoing research relating to organ optimization and functional ex vivo allograft assessment are reviewed.
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Ergebnisse der Transplantation von Spenderherzen nach normothermer Ex-vivo-Perfusion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-018-0264-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
IMPACT STATEMENT Over the past several decades, ex vivo perfusion has emerged as a promising technology for the assessment, preservation, and recovery of donor organs. Many exciting pre-clinical findings have now been translated to clinical use, and successful transplantation following ex vivo perfusion has been achieved for heart, lung, and liver. While machine perfusion provides distinct advantages over traditional cold preservation, many challenges remain, including that of long-term (multi-day) ex vivo support. Here, we provide an overview of the current status of ex vivo machine perfusion in the pre-clinical and clinical setting and share our perspective on the future direction of the field.
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Affiliation(s)
- Meghan Pinezich
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
- Department of Medicine, Columbia University, New York NY 10032, USA
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Currie M, Shudo Y, Woo Y. Successful Outcome Following Orthotopic Heart Transplantation With a Donor Half Way Across The Country. Transplant Proc 2018; 50:4062-4063. [DOI: 10.1016/j.transproceed.2018.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
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18
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Quintana-Quezada RA, Rajapreyar I, Postalian-Yrausquin A, Yeh YC, Choi S, Akkanti B, Sieg A, Weeks P, Patel M, Patel J, Nathan S, Kar B, Loyalka P, Gregoric I. Clinical Factors Implicated in Primary Graft Dysfunction After Heart Transplantation: A Single-center Experience. Transplant Proc 2017; 48:2168-71. [PMID: 27569965 DOI: 10.1016/j.transproceed.2016.02.073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/16/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND Primary graft dysfunction (PGD) is a frequent complication after cardiac transplantation and remains one of the leading causes of mortality in these patients. The objective of this case-control study is to identify donor and surgical procedure's factors associated with PGD, and further guide possible strategies to prevent PGD. METHODS Retrospective analysis of the medical records of patients who underwent cardiac transplantation at Memorial Hermann Hospital at Texas Medical Center between October 2012 and February 2015. RESULTS The study population included 99 patients, of which 18 developed PGD. Univariate analysis of donor characteristics revealed opioid use (P = .049) and death owing to anoxia (P = .021) were associated with PGD. The recipient/donor blood type match AB/A was significantly associated with PGD (P = .031). Time from brain death to aortic cross clamp (TBDACC) of ≥3 and ≥5 days were also found to be associated with PGD (P = .0011 and .0003, respectively). Multivariate analysis confirmed that patients with a time from brain death to aortic cross clamp ≥3 and ≥5 days had lesser odds of developing PGD (odds ratio, 0.098 [P = .0026] and OR, 0.092 [P = .0017], respectively]. CONCLUSIONS Our study showed that a longer time from brain death to aortic cross clamp was associated with lower odds of developing PGD. Therefore, postponing heart procurement for a few days after brain death seems to be beneficial in preventing PGD.
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Affiliation(s)
- R A Quintana-Quezada
- Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Texas Medical Center, Houston, Texas.
| | - I Rajapreyar
- Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
| | - A Postalian-Yrausquin
- Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
| | - Y C Yeh
- Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
| | - S Choi
- Division of Clinical and Translational Sciences, Department of Internal Medicine, University of Texas Medical School at Houston, Houston, Texas
| | - B Akkanti
- Division of Critical Care, Pulmonary and Sleep, University of Texas Medical School at Houston, Houston, Texas
| | - A Sieg
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, Houston, Texas
| | - P Weeks
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, Houston, Texas
| | - M Patel
- Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
| | - J Patel
- Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
| | - S Nathan
- Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
| | - B Kar
- Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
| | - P Loyalka
- Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
| | - I Gregoric
- Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
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Dronavalli VB, Rogers CA, Banner NR. Primary Cardiac Allograft Dysfunction-Validation of a Clinical Definition. Transplantation 2015; 99:1919-25. [PMID: 25742423 PMCID: PMC4548546 DOI: 10.1097/tp.0000000000000620] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Heart transplantation is an established treatment for advanced heart failure. Primary allograft dysfunction (PGD) is reported in up to 40% of transplants and is associated with a poor outcome. Methods As part of Heart Evaluation and Retrieval for Transplantation study, an investigation of the assessment of donor hearts for transplantation, we proposed a clinical definition for cardiac PGD comprising severely impaired systolic function affecting one or both ventricles accompanied by hypotension, low cardiac output, and high filling pressures occurring in the first 72 hours (in the absence of hyper acute rejection and technical surgical factors, such as cardiac tamponade). Here, we examine the prospective application of this definition to 290 heart transplants. We compared the clinical outcome of PGD and non-PGD cases. Results Ninety-four of 290 transplants developed PGD (32.4%). Inotrope use (score) was higher in the PGD group at 24, 48, and 72 hours after transplantation (P < 0.01). In the PGD group, there was a greater requirement for, intra-aortic balloon pump (50% vs 15%, P < 0.01), mechanical support (27% vs 0%, P < 0.01), and renal replacement therapy (61% vs 26%, P < 0.01). Intensive care stay was longer for recipients with PGD (median 14 vs 5 days, P < 0.01) and early mortality was higher (37% vs 4% at 30 days, 42% vs 8% at 1 year, P < 0.01). Conclusions In conclusion, our definition of PGD could be applied in a national multicenter study, and the cases it defined had more frequent complications and higher mortality. Classification of primary cardiac allograft dysfunction into three grades has been shown to be predictive of 30-day mortality in a prospective study of 290 heart transplants. This demonstrated that the classification system would be applicable for use in multicenter studies.
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Affiliation(s)
- Vamsidhar B Dronavalli
- 1 University Hospital Birmingham Queen Elizabeth Hospital, Birmingham, United Kingdom. 2 The University of Birmingham, Edgbaston, Birmingham, United Kingdom. 3 Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom. 4 The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, United Kingdom. 5 National Heart and Lung Institute and Institute of Cardiovascular Medicine and Research, Imperial College, London, United Kingdom. 6 Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom
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Abstract
Recent studies of (cost-) effectiveness in cardiothoracic transplantation have required estimation of mean survival over the lifetime of the recipients. In order to calculate mean survival, the complete survivor curve is required but is often not fully observed, so that survival extrapolation is necessary. After transplantation, the hazard function is bathtub-shaped, reflecting latent competing risks which operate additively in overlapping time periods. The poly-Weibull distribution is a flexible parametric model that may be used to extrapolate survival and has a natural competing risks interpretation. In addition, treatment effects and subgroups can be modelled separately for each component of risk. We describe the model and develop inference procedures using freely available software. The methods are applied to two problems from cardiothoracic transplantation.
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Affiliation(s)
| | - David Lunn
- Medical Research Council Biostatistics Unit, Cambridge, UK
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21
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Tevaearai Stahel HT, Unger D, Schmidli J, Gahl B, Englberger L, Kadner A, Eberle B, Mohacsi P, Carrel TP. Supplemental Cardioplegia Immediately before Graft Implantation may Improve Early Post-Transplantation Outcome. Front Surg 2014; 1:46. [PMID: 25593970 PMCID: PMC4286961 DOI: 10.3389/fsurg.2014.00046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 11/12/2014] [Indexed: 11/29/2022] Open
Abstract
Background: Preservation of cardiac grafts for transplantation is not standardized and most centers use a single administration of crystalloid solution at the time of harvesting. We investigated possible benefits of an additional dose of cardioplegia dispensed immediately before implantation. Methods: Consecutive adult cardiac transplantations (2005–2012) were reviewed. Hearts were harvested following a standard protocol (Celsior 2L, 4–8°C). In 2008, 100 ml crystalloid cardioplegic solution was added and administered immediately before implantation. Univariate and logistic regression analyses were used to investigate risk factors for post-operative graft failure and mid-term outcome. Results: A total of 81 patients, 44 standard (“Cardio−”) vs. 37 with additional cardioplegia (“Cardio+”) were analyzed. Recipients and donors were comparable in both groups. Cardio+ patients demonstrated a reduced need for defibrillation (24 vs. 48%, p = 0.03), post-operative ratio of CK-MB/CK (10.1 ± 3.9 vs. 13.3 ± 4.2%, p = 0.001), intubation time (2.0 ± 1.6 vs. 7.2 ± 11.5 days, p = 0.05), and ICU stay (3.9 ± 2.1 vs. 8.5 ± 7.8 days, p = 0.001). Actuarial survival was reduced when graft ischemic time was >180 min in Cardio− but not in Cardio+ patients (p = 0.033). Organ ischemic time >180 min (OR: 5.48, CI: 1.08–27.75), donor female gender (OR: 5.84, CI: 1.13–33.01), and recipient/donor age >60 (OR: 6.33, CI: 0.86–46.75), but not the additional cardioplegia or the observation period appeared independent predictors of post-operative acute graft failure. Conclusion: An additional dose of cardioplegia administered immediately before implantation may be a simple way to improve early and late outcome of cardiac transplantation, especially in situations of prolonged graft ischemia. A large, ideally multicentric, randomized study is desirable to verify this preliminary observation.
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Affiliation(s)
- Hendrik T Tevaearai Stahel
- Clinic for Cardiovascular Surgery, Bern University Hospital (Inselspital), University of Bern , Bern , Switzerland
| | - Darja Unger
- Clinic for Cardiovascular Surgery, Bern University Hospital (Inselspital), University of Bern , Bern , Switzerland
| | - Juerg Schmidli
- Clinic for Cardiovascular Surgery, Bern University Hospital (Inselspital), University of Bern , Bern , Switzerland
| | - Brigitta Gahl
- Clinic for Cardiovascular Surgery, Bern University Hospital (Inselspital), University of Bern , Bern , Switzerland
| | - Lars Englberger
- Clinic for Cardiovascular Surgery, Bern University Hospital (Inselspital), University of Bern , Bern , Switzerland
| | - Alexander Kadner
- Clinic for Cardiovascular Surgery, Bern University Hospital (Inselspital), University of Bern , Bern , Switzerland
| | - Balthasar Eberle
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital (Inselspital), University of Bern , Bern , Switzerland
| | - Paul Mohacsi
- Department of Cardiology, Bern University Hospital (Inselspital), University of Bern , Bern , Switzerland
| | - Thierry P Carrel
- Clinic for Cardiovascular Surgery, Bern University Hospital (Inselspital), University of Bern , Bern , Switzerland
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Donor evaluation in heart transplantation: The end of the beginning. J Heart Lung Transplant 2014; 33:1105-13. [DOI: 10.1016/j.healun.2014.05.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 05/16/2014] [Accepted: 05/28/2014] [Indexed: 12/20/2022] Open
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Messer S, Ardehali A, Tsui S. Normothermic donor heart perfusion: current clinical experience and the future. Transpl Int 2014; 28:634-42. [PMID: 24853906 DOI: 10.1111/tri.12361] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 03/05/2014] [Accepted: 05/19/2014] [Indexed: 11/28/2022]
Abstract
Following the first successful heart transplant in 1967, more than 100,000 heart transplants have been carried out worldwide. These procedures have mostly relied on cold ischaemic preservation of the donor heart because this simple technique is inexpensive and relatively reliable. However, the well-known limitations of cold ischaemic preservation imposes significant logistical challenges to heart transplantation which put a ceiling on the immediate success on this life-saving therapy, and limits the number of donor hearts that can be safely transplanted annually. Although the theoretical advantages of normothermic donor heart perfusion have been recognised for over a century, the technology to transport donor hearts in this state has only been developed within the last decade. The Organ Care System (OCS) which is designed and manufactured by TransMedics Inc. is currently the only commercially available device with this capability. This article reviews the history of normothermic heart perfusion and the clinical experience with the TransMedics OCS to date. We have also attempted to speculate on the future possibilities of this innovative and exciting technology.
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Affiliation(s)
- Simon Messer
- Transplant Unit, Papworth Hospital, Cambridgeshire, UK
| | - Abbas Ardehali
- Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Steven Tsui
- Transplant Unit, Papworth Hospital, Cambridgeshire, UK
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Koerner MM, Ghodsizad A, Schulz U, El Banayosy A, Koerfer R, Tenderich G. Normothermic Ex Vivo Allograft Blood Perfusion in Clinical Heart Transplantation. Heart Surg Forum 2014; 17:E141-5. [DOI: 10.1532/hsf98.2014332] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
<p><b>Background:</b> Cold ischemia associated with cold static storage is an independent risk factor for primary allograft failure and survival of patients after orthotopic heart transplantation. The effects of normothermic ex vivo allograft blood perfusion on outcomes after orthotopic heart transplantation compared to cold static storage have been studied.</p><p><b>Methods:</b> In this prospective, nonrandomized, single-institutional clinical study, normothermic ex vivo allograft blood perfusion has been performed using an organ care system (OCS) (TransMedics, Andover, MA, USA). Included were consecutive adult transplantation patients who received an orthotopic heart transplantation (oHTx) without a history of any organ transplantation, in the absence of a congenital heart disorder as an underlying disease and not being in need of a combined heart-lung transplantation. Furthermore, patients with fixed pulmonary hypertension, ventilator dependency, chronic renal failure, or panel reactive antibodies >20% and positive T-cell cross-matching were excluded. Inclusion criteria for donor hearts was age of <55 years, systolic blood pressure >85 mmHg at the time of final heart assessment under moderate inotropic support, heart rate of <120 bpm at the time of explantation, and left ventricular ejection fraction >40% assessed by an transcutaneous echo/Doppler study with the absence of gross wall motion abnormalities, absence of left ventricular hypertrophy, and absence of valve abnormalities. Donor hearts which were conventionally cold stored with histidine-tryptophan-ketoglutarate solution (Custodiol; Koehler Chemie, Ansbach, Germany) constituted the control group. The primary end point was the recipients' survival at 30 days and 1 and 2 years after their heart transplantation. Secondary end points were primary and chronic allograft failure, noncardiac complications, and length of hospital stay.</p><p><b>Results:</b> Over a 2-year period (January 2006 to July 2008), 159 adult cardiac allografts were transplanted. Twenty-nine were assigned for normothermic ex vivo allograft blood perfusion and 130 for cold static storage with HTK solution. Cumulative survival rates at 30 days and 1 and 2 years were 96%, 89%, and 89%, respectively, whereas in the cold static storage group survival after oHTx was 95%, 81%, and 79%. Primary graft failure was less frequent in the recipients of an oHTx who received a donor heart which had been preserved with normothermic ex vivo allograft blood perfusion using an OCS (6.89% versus 15.3%; <i>P</i> = .20). Episodes of severe acute rejection (23% versus 17.2%; <i>P</i> = .73), as well as, cases of acute renal failure requiring haemodialysis (25.3% versus 10%; <i>P</i> = .05) were more frequent diagnosed among recipients of a donor heart which had been preserved using the cold static storage. The length of hospital stay did not differ (26 days versus 28 days; <i>P</i> = .80) in both groups.</p><p><b>Conclusions:</b> Normothermic ex vivo allograft blood perfusion in adult clinical orthotopic heart transplantation contributes to better outcomes after transplantation in regard to recipient survival, incidence of primary graft dysfunction, and incidence of acute rejection.</p>
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McKeown DW, Bonser RS, Kellum JA. Management of the heartbeating brain-dead organ donor. Br J Anaesth 2012; 108 Suppl 1:i96-107. [PMID: 22194439 DOI: 10.1093/bja/aer351] [Citation(s) in RCA: 172] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The main factor limiting organ donation is the availability of suitable donors and organs. Currently, most transplants follow multiple organ retrieval from heartbeating brain-dead organ donors. However, brain death is often associated with marked physiological instability, which, if not managed, can lead to deterioration in organ function before retrieval. In some cases, this prevents successful donation. There is increasing evidence that moderation of these pathophysiological changes by active management in Intensive Care maintains organ function, thereby increasing the number and functional quality of organs available for transplantation. This strategy of active donor management requires an alteration of philosophy and therapy on the part of the intensive care unit clinicians and has significant resource implications if it is to be delivered reliably and safely. Despite increasing consensus over donor management protocols, many of their components have not yet been subjected to controlled evaluation. Hence the optimal combinations of treatment goals, monitoring, and specific therapies have not yet been fully defined. More research into the component techniques is needed.
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Affiliation(s)
- D W McKeown
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 5SA, UK.
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Clinical predictors of immunotolerance in heart transplantation. Transplant Proc 2010; 42:3183-5. [PMID: 20970644 DOI: 10.1016/j.transproceed.2010.05.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM The drugs routinely administered to prevent rejection often cause lethal side effects. Tolerant patients, therefore, should be identified to minimize these problems. The aim of this analysis was to identify clinical variables that may be associated with tolerance. METHODS We recruited 522 heart transplants (HT), excluding combined procedures, retransplantations, pediatric recipients, and subjects who died in the first year to obtain a cohort of 375 patients. Two groups were distinguished by the presence of echocardiographic, clinical, or pathological evidence of rejection in the first year (15 echocardiograms and 10 protocol biopsies per patient); 99 tolerant patients were compared with 276 nontolerant patients. We analyzed clinical variables related to morbidity and mortality. RESULTS The univariate analysis showed few differences between the groups. The multivariate analysis showed that only major histocompatibility complex (MHC)-A and MHC-DR matched recipients were significantly associated with tolerance. Thus, the likelihood of tolerance was increased by 1.7- and 2.8-fold if 1 or 2 MHC-I matches were present and by 3.4- and 3.7-fold if 1 or 2 MHC-DR matches were present, respectively survival curves showed significant differences (P=.034). Most deaths in both groups were related to immunosuppressive drugs; among tolerant subjects, deaths were due to infection and neoplasms and among nontolerant patients, deaths were due to chronic rejection, neoplasms, and infection. CONCLUSIONS The only clinical parameter that can determined whether a HT recipient was tolerant was MHC-A and MHC-DR matching. If there is matching, a reduced immunosuppressive load should be prescribed to prevent drug toxicity.
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Abstract
This paper explores the evolution of organ preservation methods from cold preservation to the more sophisticated method of warm preservation. Both methods are detailed, and the benefits and limitations of both methods are discussed.
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Affiliation(s)
- Valluvan Jeevanandam
- Section of Cardiothoracic Surgery, University of Chicago, 5841 S Maryland Ave MC 5040, Chicago, IL, 60637, USA.
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[Starting over]. Med Intensiva 2009; 33:431-3. [PMID: 19857912 DOI: 10.1016/j.medin.2009.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Accepted: 09/10/2009] [Indexed: 11/21/2022]
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