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Schmalkuche K, Rother T, Burgmann JM, Voß H, Höffler K, Dogan G, Ruhparwar A, Schmitto JD, Blasczyk R, Figueiredo C. Heart immunoengineering by lentiviral vector-mediated genetic modification during normothermic ex vivo perfusion. Front Immunol 2024; 15:1404668. [PMID: 38903492 PMCID: PMC11188324 DOI: 10.3389/fimmu.2024.1404668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/20/2024] [Indexed: 06/22/2024] Open
Abstract
Heart transplantation is associated with major hurdles, including the limited number of available organs for transplantation, the risk of rejection due to genetic discrepancies, and the burden of immunosuppression. In this study, we demonstrated the feasibility of permanent genetic engineering of the heart during ex vivo perfusion. Lentiviral vectors encoding for short hairpin RNAs targeting beta2-microglobulin (shβ2m) and class II transactivator (shCIITA) were delivered to the graft during two hours of normothermic EVHP. Highly efficient genetic engineering was indicated by stable reporter gene expression in endothelial cells and cardiomyocytes. Remarkably, swine leucocyte antigen (SLA) class I and SLA class II expression levels were decreased by 66% and 76%, respectively, in the vascular endothelium. Evaluation of lactate, troponin T, and LDH levels in the perfusate and histological analysis showed no additional cell injury or tissue damage caused by lentiviral vectors. Moreover, cytokine secretion profiles (IL-6, IL-8, and TNF-α) of non-transduced and lentiviral vector-transduced hearts were comparable. This study demonstrated the ex vivo generation of genetically engineered hearts without compromising tissue integrity. Downregulation of SLA expression may contribute to reduce the immunogenicity of the heart and support graft survival after allogeneic or xenogeneic transplantation.
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Affiliation(s)
- Katharina Schmalkuche
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
- Transregional Collaborative Research Centre 127, Hannover Medical School, Hannover, Germany
| | - Tamina Rother
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Jonathan M. Burgmann
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Henrike Voß
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Klaus Höffler
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Arjang Ruhparwar
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D. Schmitto
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Rainer Blasczyk
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
- Transregional Collaborative Research Centre 127, Hannover Medical School, Hannover, Germany
| | - Constanca Figueiredo
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
- Transregional Collaborative Research Centre 127, Hannover Medical School, Hannover, Germany
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Lee OJOJ, Bhatia I, Wan SHY, Fan KYY, Wong MKL, Au TWK, Ho CKL. Introduction of ex vivo perfusion of extended-criteria donor hearts in a single center in Asia. J Artif Organs 2024:10.1007/s10047-024-01447-x. [PMID: 38780672 DOI: 10.1007/s10047-024-01447-x] [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: 01/03/2024] [Accepted: 03/21/2024] [Indexed: 05/25/2024]
Abstract
The shortage of organs for heart transplantation has created a need to explore the use of extended-criteria organs. We report the preliminary use of normothermic TransMedics Organ Care System-an ex vivo approach to preserve extended-criteria brain-dead donor hearts. This System maintains a normal temperature, provides continuous perfusion and oxygenation, reduces ischemic time, and enables additional viability assessment options. In a retrospective single-centre study conducted from April 2020 to March 2023, four extended criteria brain-dead donor hearts were perfused and monitored using the Organ Care System. Suitability for transplantation was assessed based on stable or decreasing lactate levels, along with appropriate perfusion parameters. The Organ Care for use of the Organ Care System were coronary artery disease, left ventricular hypertrophy, high-dose inotrope use in the donor, a downtime exceeding 20 min, and a left ventricular ejection fraction of 40-50%. Three out of the four donor hearts were transplanted, while one was discarded due to rising lactate concentration. The three recipients had a higher surgical risk profile for heart transplant. All showed normal cardiac function and no primary graft dysfunction postoperatively. At 2-3 years post-transplant, all recipients have a ventricular function of > 60%, with only one showing evidence of mild rejection. The Organ Care System enables the successful transplantation of marginal donor organs in high-risk recipients, showcasing the feasibility of recruiting donors with extended criteria. This technique is safe and promising, expanding the donor pool and addressing the organ shortage in heart transplantation in Hong Kong.
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Affiliation(s)
- Oswald Joseph On Jing Lee
- Department of Cardiothoracic Surgery, New Clinical Building, Room 308, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, Hong Kong, China.
| | - Inderjeet Bhatia
- Department of Cardiothoracic Surgery, New Clinical Building, Room 308, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, Hong Kong, China.
| | - Sylvia Ho Yan Wan
- Department of Cardiothoracic Surgery, New Clinical Building, Room 308, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, Hong Kong, China
| | - Katherine Yue Yan Fan
- Cardiac Medicine Unit, 5/F Kwok Tak Seng Heart Center, Grantham Hospital, Wong Chuk Hang, Hong Kong SAR, Hong Kong, China
| | - Michael Ka Lam Wong
- Cardiac Medicine Unit, 5/F Kwok Tak Seng Heart Center, Grantham Hospital, Wong Chuk Hang, Hong Kong SAR, Hong Kong, China
| | - Timmy Wing Kuk Au
- Department of Cardiothoracic Surgery, New Clinical Building, Room 308, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, Hong Kong, China
| | - Cally Ka Lai Ho
- Department of Cardiothoracic Surgery, New Clinical Building, Room 308, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, Hong Kong, China
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Quinn J, Kotru M, Bhatia M. Con: The Use of an Organ Care System for Heart Transplant Has Led to Similar Outcomes with Expanded Donor Pools. J Cardiothorac Vasc Anesth 2024; 38:573-575. [PMID: 37985287 DOI: 10.1053/j.jvca.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Jacqueline Quinn
- Department of Anesthesiology, University of North Carolina School of Medicine, University of North Carolina Hospitals, Chapel Hill, NC.
| | | | - Meena Bhatia
- Department of Anesthesiology, University of North Carolina School of Medicine, University of North Carolina Hospitals, Chapel Hill, NC
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DiChiacchio L, Goodwin ML, Kagawa H, Griffiths E, Nickel IC, Stehlik J, Selzman CH. Heart Transplant and Donors After Circulatory Death: A Clinical-Preclinical Systematic Review. J Surg Res 2023; 292:222-233. [PMID: 37657140 DOI: 10.1016/j.jss.2023.07.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 09/03/2023]
Abstract
INTRODUCTION Heart transplantation is the treatment of choice for end-stage heart failure. There is a mismatch between the number of donor hearts available and the number of patients awaiting transplantation. Expanding the donor pool is critically important. The use of hearts donated following circulatory death is one approach to increasing the number of available donor hearts. MATERIALS AND METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines utilizing Pubmed/MEDLINE and Embase. Articles including adult human studies and preclinical animal studies of heart transplantation following donation after circulatory death were included. Studies of pediatric populations or including organs other than heart were excluded. RESULTS Clinical experience and preclinical studies are reviewed. Clinical experience with direct procurement, normothermic regional perfusion, and machine perfusion are included. Preclinical studies addressing organ function assessment and enhancement of performance of marginal organs through preischemic, procurement, preservation, and reperfusion maneuvers are included. Articles addressing the ethical considerations of thoracic transplantation following circulatory death are also reviewed. CONCLUSIONS Heart transplantation utilizing organs procured following circulatory death is a promising method to increase the donor pool and offer life-saving transplantation to patients on the waitlist living with end-stage heart failure. There is robust ongoing preclinical and clinical research to optimize this technique and improve organ yield. There are also ongoing ethical considerations that must be addressed by consensus before wide adoption of this approach.
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Affiliation(s)
- Laura DiChiacchio
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Matthew L Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Hiroshi Kagawa
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Eric Griffiths
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Ian C Nickel
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiology, University of Utah, Salt Lake City, Utah
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah.
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Schroder JN, Scheuer S, Catarino P, Caplan A, Silvestry SC, Jeevanandam V, Large S, Shah A, MacDonald P, Slaughter MS, Naka Y, Milano CA. The American Association for Thoracic Surgery 2023 Expert Consensus Document: Adult cardiac transplantation utilizing donors after circulatory death. J Thorac Cardiovasc Surg 2023; 166:856-869.e5. [PMID: 37318399 DOI: 10.1016/j.jtcvs.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/10/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Jacob N Schroder
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Sarah Scheuer
- Department of Surgery, St Vincent's Hospital, Sydney, Australia
| | | | - Arthur Caplan
- Department of Bioethics, New York University Grossman School of Medicine, New York, NY
| | | | | | | | - Ashish Shah
- Department of Cardiothoracic Surgery, Vanderbilt University, Nashville, Tenn
| | - Peter MacDonald
- Department of Surgery, St Vincent's Hospital, Sydney, Australia
| | | | - Yoshifumi Naka
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY
| | - Carmelo A Milano
- Department of Surgery, Duke University Medical Center, Durham, NC.
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Mendiola Pla M, Berrettoni S, Lee FH, Rozzi G, Marrano F, Gross RT, Evans A, Wendell DC, Lezberg P, Burattini M, Paolo lo Muzio F, Fassina L, Milano CA, Bang ML, Bowles DE, Miragoli M. Video analysis of ex vivo beating hearts during preservation on the TransMedics® organ care system. Front Cardiovasc Med 2023; 10:1216917. [PMID: 37408655 PMCID: PMC10318359 DOI: 10.3389/fcvm.2023.1216917] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/23/2023] [Indexed: 07/07/2023] Open
Abstract
Background Reliable biomarkers for assessing the viability of the donor hearts undergoing ex vivo perfusion remain elusive. A unique feature of normothermic ex vivo perfusion on the TransMedics® Organ Care System (OCS™) is that the donor heart is maintained in a beating state throughout the preservation period. We applied a video algorithm for an in vivo assessment of cardiac kinematics, video kinematic evaluation (Vi.Ki.E.), to the donor hearts undergoing ex vivo perfusion on the OCS™ to assess the feasibility of applying this algorithm in this setting. Methods Healthy donor porcine hearts (n = 6) were procured from Yucatan pigs and underwent 2 h of normothermic ex vivo perfusion on the OCS™ device. During the preservation period, serial high-resolution videos were captured at 30 frames per second. Using Vi.Ki.E., we assessed the force, energy, contractility, and trajectory parameters of each heart. Results There were no significant changes in any of the measured parameters of the heart on the OCS™ device over time as judged by linear regression analysis. Importantly, there were no significant changes in contractility during the duration of the preservation period (time 0-30 min, 918 ± 430 px/s; time 31-60 min, 1,386 ± 603 px/s; time 61-90 min, 1,299 ± 617 px/s; time 91-120 min, 1,535 ± 728 px/s). Similarly, there were no significant changes in the force, energy, or trajectory parameters. Post-transplantation echocardiograms demonstrated robust contractility of each allograft. Conclusion Vi.Ki.E. assessment of the donor hearts undergoing ex vivo perfusion is feasible on the TransMedics OCS™, and we observed that the donor hearts maintain steady kinematic measurements throughout the duration.
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Affiliation(s)
| | - Silvia Berrettoni
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Franklin H. Lee
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Giacomo Rozzi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Federica Marrano
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Ryan T. Gross
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Amy Evans
- Perfusion Services, Duke University Medical Center, Durham, NC, United States
| | - David C. Wendell
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, NC, United States
| | | | - Margherita Burattini
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Department of Surgical Sciences, Dentistry, and Maternity, University of Verona, Verona, Italy
| | | | - Lorenzo Fassina
- Department of Electrical, Computer, and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Carmelo A. Milano
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Marie-Louise Bang
- Institute of Genetic and Biomedical Research (IRGB), National Research Council (CNR), Milan Unit, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Dawn E. Bowles
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Michele Miragoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
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Xu L, Zeng Z, Niu C, Liu D, Lin S, Liu X, Szabó G, Lu J, Zheng S, Zhou P. Normothermic ex vivo heart perfusion with NLRP3 inflammasome inhibitor Mcc950 treatment improves cardiac function of circulatory death hearts after transplantation. Front Cardiovasc Med 2023; 10:1126391. [PMID: 37008319 PMCID: PMC10063899 DOI: 10.3389/fcvm.2023.1126391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/27/2023] [Indexed: 03/19/2023] Open
Abstract
BackgroundThe utilization of donation after circulatory death (DCD) hearts can enlarge the donor pool. However, DCD hearts suffer from serious ischemia/reperfusion injury (IRI). Recent studies found that the activation of NLRP3 inflammasome could play a significant role in organ IRI. Mcc950, which is a novel inhibitor of the NLRP3 inflammasome, can be applied to treat various kinds of cardiovascular diseases. Therefore, we hypothesized that the treatment of mcc950 could protect DCD hearts preserved with normothermic ex vivo heart perfusion (EVHP) against myocardial IRI via inhibiting NLRP3 inflammasome in a rat heart transplantation model of DCD.MethodsDonor-heart rats were randomly divided into four groups: Control group; Vehicle group; MP-mcc950 group; and MP + PO-mcc950 group. Mcc950 was added into the perfusate of normothermic EVHP in the MP-mcc950 and MP + PO-mcc950 groups, and was injected into the left external jugular vein after heart transplantation in the MP + PO-mcc950 group. Cardiac functional assessment was performed. The level of oxidative stress, inflammatory response, apoptosis, and NLRP3 inflammasome-associated protein of donor hearts were evaluated.ResultsThe treatment with mcc950 significantly increased the developed pressure (DP), dP/dtmax, and dP/dtmin of the left ventricular of DCD hearts at 90 min after heart transplantation in both MP-mcc950 and MP + PO-mcc950 groups. Furthermore, mcc950 added into perfusate and injected after transplantation in both MP-mcc950 and MP + PO-mcc950 groups significantly attenuated the level of oxidative stress, inflammatory response, apoptosis, and NLRP3 inflammasome compared with the vehicle group.ConclusionsNormothermic EVHP combined with mcc950 treatment can be a promising and novel DCD heart preservation strategy, which can alleviate myocardial IRI via inhibiting NLRP3 inflammasome.
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Affiliation(s)
- Liwei Xu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zifeng Zeng
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chuanjie Niu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Deshen Liu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shaoyan Lin
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiu Liu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Gábor Szabó
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
- Department of Cardiac Surgery, University of Halle (Saale), Halle, Germany
| | - Jun Lu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Correspondence: Pengyu Zhou Shaoyi Zheng Jun Lu
| | - Shaoyi Zheng
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Correspondence: Pengyu Zhou Shaoyi Zheng Jun Lu
| | - Pengyu Zhou
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Correspondence: Pengyu Zhou Shaoyi Zheng Jun Lu
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Kothari P. Ex-Vivo Preservation of Heart Allografts—An Overview of the Current State. J Cardiovasc Dev Dis 2023; 10:jcdd10030105. [PMID: 36975869 PMCID: PMC10054234 DOI: 10.3390/jcdd10030105] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
As heart transplantation continues to be the gold-standard therapy for end-stage heart failure, the supply-demand imbalance of available organs worsens. Until recently, there have been no advances in increasing the donor pool, as prolonged cold ischemic time excludes the use of certain donors. The TransMedics Organ Care System (OCS) allows for ex-vivo normothermic perfusion, which allows for a reduction of cold ischemic time and allows for long-distance procurements. Furthermore, the OCS allows for real-time monitoring and assessment of allograft quality, which can be crucial for extended-criteria donors or donation after cardiac death (DCD) donors. Conversely, the XVIVO device allows for hypothermic perfusion to preserve allografts. Despite their limitations, these devices have the potential to alleviate the supply-demand imbalance in donor availability.
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Affiliation(s)
- Perin Kothari
- School of Medicine, Stanford University, Stanford, CA 94305, USA
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9
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Nachum ER, Hogan J, Osman M, Messer S, Baxter J, Olano F, Berman M, Large S. Adult heart procurement following circulatory determined death from a donor on venous-venous extracorporeal membrane oxygenation: A case report. Perfusion 2023; 38:422-424. [PMID: 34905995 DOI: 10.1177/02676591211055305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Donation after circulatory death in the context of heart transplants is attracting interest and becoming popular in clinical practice. Activity is growing in the United Kingdom, Australia, and the United States. We believe that a prolonged warm ischemic time (time from asystole to reperfusion of the heart on an ex vivo perfusion system) is a primary indicator of adverse outcomes. However, 1.5 liters of blood must be retrieved from the right atrium following sternotomy prolonging warm ischemic time. The patient in the following case report was supported by veno-venous extra-corporeal membrane oxygenation following drowning, further complicated by aspiration-related lung failure. Following circulatory death and a mandatory five-minute stand-off period, 1.5 liters of blood was drained from the circuit as sternotomy began. Surgeons then proceeded to direct procurement of the heart, aiming for least functional warm ischemic time. Following standard implantation, the patient's postoperative recovery has been unremarkable to date.
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Affiliation(s)
| | - John Hogan
- 2144Royal Papworth Hospital, Cambridge, UK
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Lei I, Huang W, Noly PE, Naik S, Ghali M, Liu L, Pagani FD, Abou El Ela A, Pober JS, Pitt B, Platt JL, Cascalho M, Wang Z, Chen YE, Mortensen RM, Tang PC. Metabolic reprogramming by immune-responsive gene 1 up-regulation improves donor heart preservation and function. Sci Transl Med 2023; 15:eade3782. [PMID: 36753565 PMCID: PMC10068866 DOI: 10.1126/scitranslmed.ade3782] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Preservation quality of donor hearts is a key determinant of transplant success. Preservation duration beyond 4 hours is associated with primary graft dysfunction (PGD). Given transport time constraints, geographical limitations exist for donor-recipient matching, leading to donor heart underutilization. Here, we showed that metabolic reprogramming through up-regulation of the enzyme immune response gene 1 (IRG1) and its product itaconate improved heart function after prolonged preservation. Irg1 transcript induction was achieved by adding the histone deacetylase (HDAC) inhibitor valproic acid (VPA) to a histidine-tryptophan-ketoglutarate solution used for donor heart preservation. VPA increased acetylated H3K27 occupancy at the IRG1 enhancer and IRG1 transcript expression in human donor hearts. IRG1 converts aconitate to itaconate, which has both anti-inflammatory and antioxidant properties. Accordingly, our studies showed that Irg1 transcript up-regulation by VPA treatment increased nuclear translocation of nuclear factor erythroid 2-related factor 2 (Nrf2) in mice, which was accompanied by increased antioxidant protein expression [hemeoxygenase 1 (HO1) and superoxide dismutase 1 (SOD1)]. Deletion of Irg1 in mice (Irg1-/-) negated the antioxidant and cardioprotective effects of VPA. Consistent with itaconate's ability to inhibit succinate dehydrogenase, VPA treatment of human hearts increased itaconate availability and reduced succinate accumulation during preservation. VPA similarly increased IRG1 expression in pig donor hearts and improved its function in an ex vivo cardiac perfusion system both at the clinical 4-hour preservation threshold and at 10 hours. These results suggest that augmentation of cardioprotective immune-metabolomic pathways may be a promising therapeutic strategy for improving donor heart function in transplantation.
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Affiliation(s)
- Ienglam Lei
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Wei Huang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Pierre Emmanuel Noly
- Department of Cardiac Surgery, Université de Montréal, Montréal, Quebec H1T 1C8, Canada
| | - Suyash Naik
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Miriyam Ghali
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Liu Liu
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ashraf Abou El Ela
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jordan S Pober
- Department of Pathology, Yale University, New Haven, CT 06510, USA
| | - Bertram Pitt
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jeffrey L Platt
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Marilia Cascalho
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Zhong Wang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Y Eugene Chen
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Richard M Mortensen
- Departments of Molecular and Integrative Physiology, Internal Medicine, and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Paul C Tang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
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11
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Moeslund N, Ertugrul IA, Hu MA, Dalsgaard FF, Ilkjaer LB, Ryhammer P, Pedersen M, Erasmus ME, Eiskjaer H. Ex-situ oxygenated hypothermic machine perfusion in donation after circulatory death heart transplantation following either direct procurement or in-situ normothermic regional perfusion. J Heart Lung Transplant 2023; 42:730-740. [PMID: 36918339 DOI: 10.1016/j.healun.2023.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/21/2023] [Accepted: 01/31/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Heart transplantation in donation after circulatory death (DCD) relies on warm perfusion using either in situ normothermic regional perfusion (NRP) or ex situ normothermic machine perfusion. In this study, we explore an alternative: oxygenated hypothermic machine perfusion (HMP) using a novel clinically applicable perfusion system, which is compared to NRP with static cold storage (SCS). METHODS In a porcine model, a DCD setting was simulated, followed by either (1) NRP and SCS (2) NRP and HMP with the XVIVO Heart preservation system or (3) direct procurement (DPP) and HMP. After preservation, heart transplantation (HTX) was performed. After weaning from cardiopulmonary bypass (CPB), biventricular function was assessed by admittance and Swan-Ganz catheters. RESULTS Only transplanted hearts in the HMP groups showed significantly increased biventricular contractility (end-systole elastance) 2 hour post-CPB (left ventricle absolute change: NRP HMP: +1.8 ± 0.56, p = 0.047, DPP HMP: +1.5 ± 0.43, p = 0.045 and NRP SCS: +0.97 ± 0.47 mmHg/ml, p = 0.21; right ventricle absolute change: NRP HMP: +0.50 ± 0.12, p = 0.025, DPP HMP: +0.82 ± 0.23, p = 0.039 and NRP SCS: +0.28 ± 0.26, p = 0.52) while receiving significantly less dobutamine to maintain a cardiac output >4l/min compared to SCS. Diastolic function was preserved in all groups. Post-HTX, both HMP groups showed significantly less increments in plasma troponin T compared to SCS. CONCLUSION In DCD HTX, increased biventricular contractility post-HTX was only observed in hearts preserved with HMP. In addition, the need for inotropic support and signs of myocardial damage were lower in the HMP groups. DCD HTX can be successfully performed using DPP followed by preservation with HMP in a preclinical setting.
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Affiliation(s)
- Niels Moeslund
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department for Clinical Medicine-Comparative Medicine Lab, Aarhus University, Aarhus, Denmark; Department for Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark.
| | - Imran A Ertugrul
- Department for Cardiothoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Michiel A Hu
- Department for Cardiothoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Frederik Flyvholm Dalsgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department for Clinical Medicine-Comparative Medicine Lab, Aarhus University, Aarhus, Denmark
| | - Lars Bo Ilkjaer
- Department for Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Pia Ryhammer
- Department for Anesthesiology, Region Hospital Silkeborg, Silkeborg, Denmark
| | - Michael Pedersen
- Department for Clinical Medicine-Comparative Medicine Lab, Aarhus University, Aarhus, Denmark
| | - Michiel E Erasmus
- Department for Cardiothoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hans Eiskjaer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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12
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Heart Transplantation From DCD Donors in Australia: Lessons Learned From the First 74 Cases. Transplantation 2023; 107:361-371. [PMID: 36044329 DOI: 10.1097/tp.0000000000004294] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Heart transplantation from donation after circulatory death (DCD) donors has the potential to substantially increase overall heart transplant activity. The aim of this report is to review the first 8 y of our clinical heart transplant program at St Vincent's Hospital Sydney, to describe how our program has evolved and to report the impact that changes to our retrieval protocols have had on posttransplant outcomes. Since 2014, we have performed 74 DCD heart transplants from DCD donors utilizing a direct procurement protocol followed by normothermic machine perfusion. Changes to our retrieval protocol have resulted in a higher retrieval rate from DCD donors and fewer rejections of DCD hearts during normothermic machine perfusion. Compared with our previously reported early experience in the first 23 transplants, we have observed a significant reduction in the incidence of severe primary graft dysfunction from 35% (8/23) to 8% (4/51) in the subsequent 51 transplant recipients ( P < 0.01). The only withdrawal time interval significantly associated with severe primary graft dysfunction was the asystolic warm ischemic time: 15 (12-17) versus 13 (11-14) min ( P < 0.05). One- and 5-y survival of DCD heart transplant recipients was 94% and 88%, comparable to that of a contemporary cohort of donation after brain death recipients: 87 and 81% ( P -value was not significant). In conclusion, heart transplantation from DCD donors has become a major contributor to our overall transplant activity accounting for almost 30% of all transplants performed by our program in the last 2 y, with similar DCD and donation after brain death outcomes.
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13
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Buratto E, Konstantinov IE. Commentary: Combined heart-lung procurement: Avoiding the bottleneck effect. J Thorac Cardiovasc Surg 2023; 165:197-198. [PMID: 33745709 DOI: 10.1016/j.jtcvs.2021.02.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Edward Buratto
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
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14
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Meredith T, Scheuer S, Hoffman M, Joshi Y, Kathir K, Gunalingam B, Roy D, Wilson S, Jansz P, Macdonald P, Muller D. Coronary angiography of the ex-situ beating donor heart in a portable organ care system. Catheter Cardiovasc Interv 2022; 100:1252-1260. [PMID: 36321629 PMCID: PMC10091975 DOI: 10.1002/ccd.30455] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/10/2022] [Accepted: 10/15/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To determine safety and feasibility of ex-situ coronary angiography. BACKGROUND To cater for the perpetually growing demand for heart donors, interest in donation following circulatory death (DCD) has been rekindled. Further pursuit of donor pool expansion has led to eligibility extension to "marginal" donors who are at higher risk of coronary artery disease (CAD). Excluding CAD in potentially eligible DCD donors, for whom ante-mortem angiography is commonly not permitted, is therefore challenging. Ex-situ coronary angiography serves as an ethical and feasible diagnostic tool to assess for preclusive CAD. METHODS We undertook a systematic review of the published literature and institutional retrospective review of case experience with ex-situ coronary angiography of donor hearts, supported by a portable organ care system. RESULTS Combined literature and institutional case review yielded nine total cases of ex-situ coronary angiography of donor human hearts plus one experimental porcine model. Of the eight cases of ex-situ coronary angiography performed at our institute, all were conducted without complication or injury to the allograft. Two thirds of reported human cases have proceeded to successful transplantation. CONCLUSIONS Diagnostic coronary angiography of the ex-situ beating donor heart is safe, feasible, and demonstrates novel clinical utility in mitigating subsequent transplantation of unsuitable allografts. In the setting of suspected coronary atherosclerosis of the donor heart, which may preclude favorable transplantation outcomes, ex-situ coronary angiography should be considered at eligible transplant centers.
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Affiliation(s)
- Thomas Meredith
- Department of Interventional Cardiology, St Vincent's Hospital, Sydney, New South Wales, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia.,Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Sarah Scheuer
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia.,Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Heart and Lung Transplantation, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Michael Hoffman
- Department of Interventional Cardiology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Yashutosh Joshi
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia.,Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Heart and Lung Transplantation, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Krishna Kathir
- Department of Interventional Cardiology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Brendan Gunalingam
- Department of Interventional Cardiology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - David Roy
- Department of Interventional Cardiology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Stephanie Wilson
- Department of Interventional Cardiology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Paul Jansz
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia.,Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Heart and Lung Transplantation, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Peter Macdonald
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia.,Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Heart and Lung Transplantation, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - David Muller
- Department of Interventional Cardiology, St Vincent's Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
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15
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Expanding Donor Heart Utilization Through Machine Perfusion Technologies. CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-022-00375-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Abstract
Purpose of Review
Recent advances in donor heart preservation have allowed the utilization of hearts that would typically be discarded due to prolonged ischemic times or donation via the circulatory death pathway. This review will discuss recent advances in donor heart preservation including optimization of machine perfusion technologies and future strategies of potential benefit for the donor heart and transplant outcomes.
Recent Findings
Improvements in organ preservation strategies have enabled retrieval of donor hearts that were not ideal for static cold storage. Machine perfusion (normothermic and hypothermic) and normothermic regional perfusion have ultimately expanded the donor pool for adult heart transplantation. Xenotransplantation has also incorporated machine perfusion for porcine donor heart preservation.
Summary
Traditional static cold storage is feasible for non-complex donors and transplants. Machine perfusion has enabled increased donor heart utilization however optimal preservation strategies are dependent on the donor criteria, predicted ischemic times and surgical complexity.
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16
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Alomari M, Garg P, Yazji JH, Wadiwala IJ, Alamouti-fard E, Hussain MWA, Elawady MS, Jacob S. Is the Organ Care System (OCS) Still the First Choice With Emerging New Strategies for Donation After Circulatory Death (DCD) in Heart Transplant? Cureus 2022; 14:e26281. [PMID: 35754437 PMCID: PMC9229932 DOI: 10.7759/cureus.26281] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 12/14/2022] Open
Abstract
The scarcity of donor hearts continues to be a challenge in transplants for advanced heart failure patients. With an increasing number of patients on the waiting list for a heart transplant, the discrepancy in the number between donors and recipients is gradually increasing and poses a new challenge that plagues the healthcare systems when it comes to the heart. Several technologies have been developed to expand the donor pool in recent years. One such method is the organ care system (OCS). The standard method of organ preservation is the static cold storage (SCS) method which allows up to four hours of safe preservation of the heart. However, beyond four hours of cold ischemia, the incidence of primary graft dysfunction increases significantly. OCS keeps the heart perfused close to the physiological state beyond the four hours with superior results, which allows us to travel further and longer distances, leading to expansion in the donor pool. In this review, we discuss the OCS system, its advantages, and shortcomings.
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17
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High Oxygenation During Normothermic Regional Perfusion After Circulatory Death Is Beneficial on Donor Cardiac Function in a Porcine Model. Transplantation 2022; 106:e326-e335. [PMID: 35546529 DOI: 10.1097/tp.0000000000004164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Thoracoabdominal normothermic regional perfusion (NRP) is a new method for in situ reperfusion and reanimation of potential donor organs in donation after circulatory death by reperfusion of the thoracic and abdominal organs with oxygenated blood. We investigated effects of high oxygenation (HOX) versus low oxygenation (LOX) during NRP on donor heart function in a porcine model. METHODS Pigs (80 kg) underwent a 15-min anoxic cardiac arrest followed by cardiac reanimation on NRP using a heart-lung bypass machine with subsequent assessment 180 minutes post-NRP. The animals were randomized to HOX (FiO2 1.0) or LOX (FiO2 0.21 increased to 0.40 during NRP). Hemodynamic data were obtained by invasive blood pressure and biventricular pressure-volume measurements. Blood gases, biomarkers of inflammation, and oxidative stress were measured. RESULTS Eight of 9 animals in the HOX group and 7 of 10 in the LOX group were successfully weaned from NRP. Right ventricular end-systole elastance was significantly improved in the HOX group compared with the LOX group, whereas left ventricular end-systole elastance was preserved at baseline levels. Post-NRP cardiac output, mean arterial, central venous, and pulmonary capillary wedge pressure were all comparable to baseline. Creatinine kinase-MB increased more in the LOX group than the HOX group, whereas proinflammatory cytokines increased more in the HOX group than the LOX group. No difference was found in oxidative stress between groups. CONCLUSIONS All hearts weaned from NRP showed acceptable hemodynamic function for transplantation. Hearts exposed to LOX showed more myocardial damage and showed poorer contractile performance than hearts reperfused with high oxygen.
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18
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Chen Q, Singer-Englar T, Kobashigawa JA, Roach A, Emerson D, Megna D, Ramzy D, Catarino P, Patel JK, Kittleson M, Czer L, Chikwe J, Esmailian F. Long-term outcomes after heart transplantation using ex vivo allograft perfusion in standard risk donors: A single-center experience. Clin Transplant 2022; 36:e14591. [PMID: 35030278 PMCID: PMC11144456 DOI: 10.1111/ctr.14591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/20/2021] [Accepted: 01/10/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The Organ Care System (OCS) is an ex vivo perfusion platform for donor heart preservation. Short/mid-term post-transplant outcomes after its use are comparable to standard cold storage (CS). We evaluated long-term outcomes following its use. METHODS Between 2011 and 2013, 38 patients from a single center were randomized as a part of the PROCEED II trial to receive allografts preserved with CS (n = 19) or OCS (n = 19). Endpoints included 8-year survival, survival free from graft-related deaths, freedom from cardiac allograft vasculopathy (CAV), non-fatal major adverse cardiac events (NF-MACE), and rejections. RESULTS Eight-year survival was 57.9% in the OCS group and 73.7% in the CS group (p = .24). Freedom from CAV was 89.5% in the OCS group and 67.8% in the CS group (p = .13). Freedom from NF-MACE was 89.5% in the OCS group and 67.5% in the CS group (p = .14). Eight-year survival free from graft-related death was equivalent between the two groups (84.2% vs. 84.2%, p = .93). No differences in rejection episodes were observed (all p > .5). CONCLUSIONS In select patients receiving OCS preserved allografts, late post-transplant survival trended lower than those transplanted with an allograft preserved with CS. This is based on a small single-center series, and larger numbers are needed to confirm these findings.
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Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Tahli Singer-Englar
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon A. Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Amy Roach
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Danny Ramzy
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh K. Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lawrence Czer
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Fardad Esmailian
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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19
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Kirste G. Cold but not too cold: advances in hypothermic and normothermic organ perfusion. KOREAN JOURNAL OF TRANSPLANTATION 2022; 36:2-14. [PMID: 35769433 PMCID: PMC9235527 DOI: 10.4285/kjt.22.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022] Open
Abstract
Transplantation is the method of choice and, in many cases, the only method of treatment for patients with end-stage organ disease. Excellent results have been achieved, and the main focus today is to extend the number of available donors. The use of extended-criteria donors or donors after circulatory death is standard, but is accompanied by an increased risk of ischemia reperfusion injury. This review presents newly developed machine perfusion techniques using hypothermic, subnormothermic, or normothermic conditions, with or without oxygenation. Possibilities for treatment and quality assessment in decision-making about organ acceptability are also discussed.
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Affiliation(s)
- Guenter Kirste
- Department of Surgery, University Hospital of Freiburg, Albert Ludwig University of Freiburg, Freiburg im Breisgau, Germany
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20
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Tolomeo AM, Fabozzo A, Malvicini R, De Lazzari G, Bisaccia P, Gaburro G, Arcidiacono D, Notarangelo D, Caicci F, Zanella F, Marchesan M, Yannarelli G, Santovito G, Muraca M, Gerosa G. Temperature-Related Effects of Myocardial Protection Strategies in Swine Hearts after Prolonged Warm Ischemia. Antioxidants (Basel) 2022; 11:antiox11030476. [PMID: 35326125 PMCID: PMC8944743 DOI: 10.3390/antiox11030476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 02/04/2023] Open
Abstract
Insufficient supply of cardiac grafts represents a severe obstacle in heart transplantation. Donation after circulatory death (DCD), in addition to conventional donation after brain death, is one promising option to overcome the organ shortage. However, DCD organs undergo an inevitably longer period of unprotected warm ischemia between circulatory arrest and graft procurement. In this scenario, we aim to improve heart preservation after a warm ischemic period of 20 min by testing different settings of myocardial protective strategies. Pig hearts were collected from a slaughterhouse and assigned to one of the five experimental groups: baseline (BL), cold cardioplegia (CC), cold cardioplegia + adenosine (CC-ADN), normothermic cardioplegia (NtC + CC) or normothermic cardioplegia + cold cardioplegia + adenosine (NtC-ADN + CC). After treatment, tissue biopsies were taken to assess mitochondrial morphology, antioxidant enzyme activity, lipid peroxidation and cytokine and chemokine expressions. NtC + CC treatment significantly prevented mitochondria swelling and mitochondrial cristae loss. Moreover, the antioxidant enzyme activity was lower in this group, as was lipid peroxidation, and the pro-inflammatory chemokine GM-CSF was diminished. Finally, we demonstrated that normothermic cardioplegia preserved mitochondria morphology, thus preventing oxidative stress and the subsequent inflammatory response. Therefore, normothermic cardioplegia is a better approach to preserve the heart after a warm ischemia period, with respect to cold cardioplegia, before transplantation.
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Affiliation(s)
- Anna Maria Tolomeo
- Department of Cardiac, Thoracic and Vascular Science and Public Health, University of Padova, 35128 Padua, Italy; (A.M.T.); (D.N.); (G.G.)
- L.i.f.e.L.a.b. Program, Consorzio per la Ricerca Sanitaria (CORIS), Veneto Region, 35128 Padua, Italy; (R.M.); (G.D.L.); (M.M.)
| | - Assunta Fabozzo
- L.i.f.e.L.a.b. Program, Consorzio per la Ricerca Sanitaria (CORIS), Veneto Region, 35128 Padua, Italy; (R.M.); (G.D.L.); (M.M.)
- Cardiac Surgery Unit, Hospital University of Padova, 35128 Padua, Italy;
- Correspondence: ; Tel.: +39-049-8212413
| | - Ricardo Malvicini
- L.i.f.e.L.a.b. Program, Consorzio per la Ricerca Sanitaria (CORIS), Veneto Region, 35128 Padua, Italy; (R.M.); (G.D.L.); (M.M.)
- Department of Women’s and Children’s Health, University of Padova, 35128 Padua, Italy;
- Instituto de Medicina Traslacional, Trasplante y Bioingeniería (IMeTTyB) CONICET—Universidad Favaloro), Buenos Aires 1078, Argentina;
| | - Giada De Lazzari
- L.i.f.e.L.a.b. Program, Consorzio per la Ricerca Sanitaria (CORIS), Veneto Region, 35128 Padua, Italy; (R.M.); (G.D.L.); (M.M.)
- Department of Women’s and Children’s Health, University of Padova, 35128 Padua, Italy;
| | - Paola Bisaccia
- Department of Women’s and Children’s Health, University of Padova, 35128 Padua, Italy;
| | - Gianluca Gaburro
- Department of Biology, University of Padova, 35128 Padua, Italy; (G.G.); (F.C.); (G.S.)
| | - Diletta Arcidiacono
- Gastroenterology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy;
| | - Denni Notarangelo
- Department of Cardiac, Thoracic and Vascular Science and Public Health, University of Padova, 35128 Padua, Italy; (A.M.T.); (D.N.); (G.G.)
| | - Federico Caicci
- Department of Biology, University of Padova, 35128 Padua, Italy; (G.G.); (F.C.); (G.S.)
| | - Fabio Zanella
- Cardiac Surgery Unit, Hospital University of Padova, 35128 Padua, Italy;
| | | | - Gustavo Yannarelli
- Instituto de Medicina Traslacional, Trasplante y Bioingeniería (IMeTTyB) CONICET—Universidad Favaloro), Buenos Aires 1078, Argentina;
| | - Gianfranco Santovito
- Department of Biology, University of Padova, 35128 Padua, Italy; (G.G.); (F.C.); (G.S.)
| | - Maurizio Muraca
- L.i.f.e.L.a.b. Program, Consorzio per la Ricerca Sanitaria (CORIS), Veneto Region, 35128 Padua, Italy; (R.M.); (G.D.L.); (M.M.)
- Department of Women’s and Children’s Health, University of Padova, 35128 Padua, Italy;
| | - Gino Gerosa
- Department of Cardiac, Thoracic and Vascular Science and Public Health, University of Padova, 35128 Padua, Italy; (A.M.T.); (D.N.); (G.G.)
- L.i.f.e.L.a.b. Program, Consorzio per la Ricerca Sanitaria (CORIS), Veneto Region, 35128 Padua, Italy; (R.M.); (G.D.L.); (M.M.)
- Cardiac Surgery Unit, Hospital University of Padova, 35128 Padua, Italy;
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21
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Abstract
PURPOSE OF REVIEW To highlight the current global experience with DCD heart transplantation and explore the evolution of, and compare preservation strategies; examine early clinical outcomes, and discuss the growing use of DCD donors as a new frontier in heart transplantation. RECENT FINDINGS The two strategies of DCD heart preservation include NMP using the OCS Heart and TA-NRP followed by either: NMP or CSS. Better understanding the limits of cold ischaemia following TA-NRP will aid in distant procurement. Asystolic warm ischaemia plays an important role in determining immediate post-operative graft function and potential need for mechanical support. Large volume DCD heart transplant units show no difference in survival between DCD and DBD donor heart transplants. In a previously non-utilised source of donor hearts, often viewed as an "unknown frontier" in heart transplantation, DCD hearts are a suitable alternative to brain-dead donor hearts and are likely to remain a permanent part of the heart transplantation landscape. Global uptake is currently increasing, and as understanding of preservation strategies and tolerable ischaemic times improve, utilisation of DCD hearts will continue to grow.
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22
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See Hoe LE, Wildi K, Obonyo NG, Bartnikowski N, McDonald C, Sato K, Heinsar S, Engkilde-Pedersen S, Diab S, Passmore MR, Wells MA, Boon AC, Esguerra A, Platts DG, James L, Bouquet M, Hyslop K, Shuker T, Ainola C, Colombo SM, Wilson ES, Millar JE, Malfertheiner MV, Reid JD, O'Neill H, Livingstone S, Abbate G, Sato N, He T, von Bahr V, Rozencwajg S, Byrne L, Pimenta LP, Marshall L, Nair L, Tung JP, Chan J, Haqqani H, Molenaar P, Li Bassi G, Suen JY, McGiffin DC, Fraser JF. A clinically relevant sheep model of orthotopic heart transplantation 24 h after donor brainstem death. Intensive Care Med Exp 2021; 9:60. [PMID: 34950993 PMCID: PMC8702587 DOI: 10.1186/s40635-021-00425-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Heart transplantation (HTx) from brainstem dead (BSD) donors is the gold-standard therapy for severe/end-stage cardiac disease, but is limited by a global donor heart shortage. Consequently, innovative solutions to increase donor heart availability and utilisation are rapidly expanding. Clinically relevant preclinical models are essential for evaluating interventions for human translation, yet few exist that accurately mimic all key HTx components, incorporating injuries beginning in the donor, through to the recipient. To enable future assessment of novel perfusion technologies in our research program, we thus aimed to develop a clinically relevant sheep model of HTx following 24 h of donor BSD.
Methods BSD donors (vs. sham neurological injury, 4/group) were hemodynamically supported and monitored for 24 h, followed by heart preservation with cold static storage. Bicaval orthotopic HTx was performed in matched recipients, who were weaned from cardiopulmonary bypass (CPB), and monitored for 6 h. Donor and recipient blood were assayed for inflammatory and cardiac injury markers, and cardiac function was assessed using echocardiography. Repeated measurements between the two different groups during the study observation period were assessed by mixed ANOVA for repeated measures.
Results Brainstem death caused an immediate catecholaminergic hemodynamic response (mean arterial pressure, p = 0.09), systemic inflammation (IL-6 - p = 0.025, IL-8 - p = 0.002) and cardiac injury (cardiac troponin I, p = 0.048), requiring vasopressor support (vasopressor dependency index, VDI, p = 0.023), with normalisation of biomarkers and physiology over 24 h. All hearts were weaned from CPB and monitored for 6 h post-HTx, except one (sham) recipient that died 2 h post-HTx. Hemodynamic (VDI - p = 0.592, heart rate - p = 0.747) and metabolic (blood lactate, p = 0.546) parameters post-HTx were comparable between groups, despite the observed physiological perturbations that occurred during donor BSD. All p values denote interaction among groups and time in the ANOVA for repeated measures. Conclusions We have successfully developed an ovine HTx model following 24 h of donor BSD. After 6 h of critical care management post-HTx, there were no differences between groups, despite evident hemodynamic perturbations, systemic inflammation, and cardiac injury observed during donor BSD. This preclinical model provides a platform for critical assessment of injury development pre- and post-HTx, and novel therapeutic evaluation. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00425-4.
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Affiliation(s)
- Louise E See Hoe
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia. .,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia. .,School of Pharmacy and Medical Sciences, Griffith University, Southport, QLD, Australia.
| | - Karin Wildi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Cardiovascular Research Institute Basel, Basel, Switzerland
| | - Nchafatso G Obonyo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Wellcome Trust Centre for Global Health Research, Imperial College London, London, UK.,Initiative to Develop African Research Leaders (IDeAL), Kilifi, Kenya
| | - Nicole Bartnikowski
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Charles McDonald
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Second Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Sanne Engkilde-Pedersen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Research and Development, Australian Red Cross Lifeblood, Brisbane, QLD, Australia
| | - Sara Diab
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Margaret R Passmore
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Matthew A Wells
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Pharmacy and Medical Sciences, Griffith University, Southport, QLD, Australia
| | - Ai-Ching Boon
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Arlanna Esguerra
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Research and Development, Australian Red Cross Lifeblood, Brisbane, QLD, Australia
| | - David G Platts
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Lynnette James
- Department of Cardiac Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Mahe Bouquet
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Kieran Hyslop
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Tristan Shuker
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Carmen Ainola
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Sebastiano M Colombo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Milan, Italy
| | - Emily S Wilson
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jonathan E Millar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Roslin Institute, University of Edinburgh, Edinburgh, UK
| | - Maximillian V Malfertheiner
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Janice D Reid
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Hollier O'Neill
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Samantha Livingstone
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Gabriella Abbate
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Noriko Sato
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Ting He
- Department of Cardiac Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Viktor von Bahr
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Sacha Rozencwajg
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Pitié-Salpêtrière University Hospital, Paris, France
| | - Liam Byrne
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,The Canberra Hospital Intensive Care, Garran, ACT, Australia.,Australia National University, Canberra, ACT, Australia
| | - Leticia P Pimenta
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Lachlan Marshall
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Cardiac Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital, Brisbane, QLD, Australia
| | - Lawrie Nair
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital, Brisbane, QLD, Australia
| | - John-Paul Tung
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Research and Development, Australian Red Cross Lifeblood, Brisbane, QLD, Australia.,Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Jonathan Chan
- Prince Charles Hospital, Brisbane, QLD, Australia.,School of Medicine, Griffith University, Southport, QLD, Australia
| | - Haris Haqqani
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Prince Charles Hospital, Brisbane, QLD, Australia
| | - Peter Molenaar
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Faculty of Health, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - David C McGiffin
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Cardiothoracic Surgery and Transplantation, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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23
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Sun YF, Wang ZW, Zhang J, Cai J, Shi F, Dong NG. Current Status of and Opinions on Heart Transplantation in China. Curr Med Sci 2021; 41:841-846. [PMID: 34652629 PMCID: PMC8517940 DOI: 10.1007/s11596-021-2444-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/01/2020] [Indexed: 11/29/2022]
Abstract
The purpose of this review is to provide a comprehensive update on recent advances in heart transplantation in China. Despite advances in pharmacologic and device treatment of chronic heart failure, long-term morbidity and mortality remain high, and many patients progress to endstage heart failure. Heart transplantation has become standard treatment for selected patients with end-stage heart failure, though challenges still exist. However, multiple advances over the past few years will improve the survival and quality-of-life of heart transplant recipients. This article elaborates on the specific characteristics of heart transplantation in China, the current issues, development trends, and related experiences with heart transplantation in Wuhan Union Hospital.
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Affiliation(s)
- Yong-feng Sun
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Zhi-wen Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Jing Zhang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Jie Cai
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Feng Shi
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
| | - Nian-guo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 China
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24
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Lu J, Xu L, Zeng Z, Xue C, Li J, Chen X, Zhou P, Lin S, Liao Y, Du X, Yang R, Zheng S. Normothermic ex vivo Heart Perfusion Combined With Melatonin Enhances Myocardial Protection in Rat Donation After Circulatory Death Hearts via Inhibiting NLRP3 Inflammasome-Mediated Pyroptosis. Front Cell Dev Biol 2021; 9:733183. [PMID: 34532321 PMCID: PMC8438322 DOI: 10.3389/fcell.2021.733183] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/11/2021] [Indexed: 01/06/2023] Open
Abstract
Objective The adoption of hearts from donation after circulatory death (DCD) is a promising approach for the shortage of suitable organs in heart transplantation. However, DCD hearts suffer from serious ischemia/reperfusion injury (IRI). Recent studies demonstrate that nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome-mediated pyroptosis is a novel target to ameliorate myocardial IRI. Melatonin is shown to inhibit NLRP3 inflammasome-mediated pyroptosis. Therefore, this study is designed to verify the hypothesis that melatonin can protect the heart graft preserved with ex vivo heart perfusion (EVHP) against myocardial IRI via inhibiting NLRP3 inflammasome-mediated pyroptosis in a rat model of DCD. Methods Donor-heart rats were randomly divided into three groups: (1) Control group: non-DCD hearts were harvested from heart-beating rats and immediately preserved with allogenic blood-based perfusate at constant flow for 105 min in the normothermic EVHP system; (2) DCD-vehicle group; and (3) DCD-melatonin group: rats were subjected to the DCD procedure with 25 min of warm ischemia injury and preserved by the normothermic EVHP system for 105 min. Melatonin (200 μmol/L) or vehicle was perfused in the cardioplegia and throughout the whole EVHP period. Cardiac functional assessment was performed every 30 min during EVHP. The level of oxidative stress, inflammatory response, apoptosis, and NLRP3 inflammasome-mediated pyroptosis of heart grafts submitted to EVHP were evaluated. Results Twenty five-minute warm ischemia injury resulted in a significant decrease in the developed pressure (DP), dP/dt max , and dP/dt min of left ventricular of the DCD hearts, while the treatment with melatonin significantly increased the DP, dP/dt max of the left ventricular of DCD hearts compared with DCD-vehicle group. Furthermore, warm ischemia injury led to a significant increase in the level of oxidative stress, inflammatory response, apoptosis, and NLRP3 inflammasome-mediated pyroptosis in the hearts preserved with EVHP. However, melatonin added in the cardioplegia and throughout the EVHP period significantly attenuated the level of oxidative stress, inflammatory response, apoptosis, and NLRP3 inflammasome-mediated pyroptosis compared with DCD-vehicle group. Conclusion EVHP combined with melatonin post-conditioning attenuates myocardial IRI in DCD hearts by inhibiting NLRP3 inflammasome-mediated pyroptosis, which might expand the donor pool by the adoption of transplantable DCD hearts.
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Affiliation(s)
- Jun Lu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Liwei Xu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zifeng Zeng
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chuqing Xue
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jiale Li
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiong Chen
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Pengyu Zhou
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shaoyan Lin
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuhui Liao
- Molecular Diagnosis and Treatment Center for Infectious Diseases, Dermatology Hospital, Southern Medical University, Guangzhou, China
| | - Xianjin Du
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Ronghua Yang
- Department of Burn Surgery, The First People's Hospital of Foshan, Foshan, China
| | - Shaoyi Zheng
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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25
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Guidetti F, Arrigo M, Frank M, Mikulicic F, Sokolski M, Aser R, Wilhelm MJ, Flammer AJ, Ruschitzka F, Winnik S. Treatment of Advanced Heart Failure-Focus on Transplantation and Durable Mechanical Circulatory Support: What Does the Future Hold? Heart Fail Clin 2021; 17:697-708. [PMID: 34511216 DOI: 10.1016/j.hfc.2021.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Heart transplantation (HTx) is the treatment of choice in patients with late-stage advanced heart failure (Advanced HF). Survival rates 1, 5, and 10 years after transplantation are 87%, 77%, and 57%, respectively, and the average life expectancy is 9.16 years. However, because of the donor organ shortage, waiting times often exceed life expectancy, resulting in a waiting list mortality of around 20%. This review aims to provide an overview of current standard, recent advances, and future developments in the treatment of Advanced HF with a focus on long-term mechanical circulatory support and HTx.
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Affiliation(s)
- Federica Guidetti
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland.
| | - Mattia Arrigo
- Department of Internal Medicine, Triemli Hospital Zürich, Birmensdorferstrasse 497, 8063 Zürich, Switzerland
| | - Michelle Frank
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Fran Mikulicic
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Mateusz Sokolski
- Department of Heart Diseases, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Raed Aser
- Department of Cardiac Surgery, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Markus J Wilhelm
- Department of Cardiac Surgery, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Andreas J Flammer
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Stephan Winnik
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
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26
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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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27
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Redd MA, Scheuer SE, Saez NJ, Yoshikawa Y, Chiu HS, Gao L, Hicks M, Villanueva JE, Joshi Y, Chow CY, Cuellar-Partida G, Peart JN, See Hoe LE, Chen X, Sun Y, Suen JY, Hatch RJ, Rollo B, Xia D, Alzubaidi MAH, Maljevic S, Quaife-Ryan GA, Hudson JE, Porrello ER, White MY, Cordwell SJ, Fraser JF, Petrou S, Reichelt ME, Thomas WG, King GF, Macdonald PS, Palpant NJ. Therapeutic Inhibition of Acid Sensing Ion Channel 1a Recovers Heart Function After Ischemia-Reperfusion Injury. Circulation 2021; 144:947-960. [PMID: 34264749 DOI: 10.1161/circulationaha.121.054360] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Ischemia-reperfusion injury (IRI) is one of the major risk factors implicated in morbidity and mortality associated with cardiovascular disease. During cardiac ischemia, the build-up of acidic metabolites results in decreased intracellular and extracellular pH that can reach as low as 6.0-6.5. The resulting tissue acidosis exacerbates ischemic injury and significantly impacts cardiac function. Methods: We used genetic and pharmacological methods to investigate the role of acid sensing ion channel 1a (ASIC1a) in cardiac IRI at the cellular and whole organ level. Human induced pluripotent stem cell derived cardiomyocytes (hiPSC-CMs) as well as ex vivo and in vivo models of IRI were used to test the efficacy of ASIC1a inhibitors as pre- and post-conditioning therapeutic agents. Results: Analysis of human complex trait genetics indicate that variants in the ASIC1 genetic locus are significantly associated with cardiac and cerebrovascular ischemic injuries. Using hiPSC-CMs in vitro and murine ex vivo heart models, we demonstrate that genetic ablation of ASIC1a improves cardiomyocyte viability after acute IRI. Therapeutic blockade of ASIC1a using specific and potent pharmacological inhibitors recapitulates this cardioprotective effect. We used an in vivo model of myocardial infarction (MI) and two models of ex vivo donor heart procurement and storage as clinical models to show that ASIC1a inhibition improves post-IRI cardiac viability. Use of ASIC1a inhibitors as pre- or post-conditioning agents provided equivalent cardioprotection to benchmark drugs, including the sodium-hydrogen exchange inhibitor zoniporide. At the cellular and whole organ level, we show that acute exposure to ASIC1a inhibitors has no impact on cardiac ion channels regulating baseline electromechanical coupling and physiological performance. Conclusions: Collectively, our data provide compelling evidence for a novel pharmacological strategy involving ASIC1a blockade as a cardioprotective therapy to improve the viability of hearts subjected to IRI.
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Affiliation(s)
- Meredith A Redd
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Australia (M.A.R., L.E.S.H., J.Y.S., J.F.F.)
| | - Sarah E Scheuer
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
- Cardiopulmonary Transplant Unit (S.E.S., Y.J., P.S.M.), St Vincent's Hospital, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia (S.E.S., M.H., J.E.V., Y.J., P.S.M.)
| | - Natalie J Saez
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Science (N.J.S., G.F.K.), The University of Queensland, St Lucia, Australia
| | - Yusuke Yoshikawa
- School of Biomedical Sciences (Y.Y., M.E.R., W.G.T.), The University of Queensland, St Lucia, Australia
| | - Han Sheng Chiu
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
| | - Ling Gao
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
| | - Mark Hicks
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
- Department of Pharmacology (M.H.), St Vincent's Hospital, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia (S.E.S., M.H., J.E.V., Y.J., P.S.M.)
| | - Jeanette E Villanueva
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
- Faculty of Medicine, University of New South Wales, Sydney, Australia (S.E.S., M.H., J.E.V., Y.J., P.S.M.)
| | - Yashutosh Joshi
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
- Cardiopulmonary Transplant Unit (S.E.S., Y.J., P.S.M.), St Vincent's Hospital, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia (S.E.S., M.H., J.E.V., Y.J., P.S.M.)
| | - Chun Yuen Chow
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
| | - Gabriel Cuellar-Partida
- The University of Queensland Diamantina Institute, Faculty of Medicine and Translational Research Institute, Woolloongabba, Australia (G.C.-P.)
| | - Jason N Peart
- School of Medical Science, Griffith University, Southport, Australia (J.N.P.)
| | - Louise E See Hoe
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Australia (M.A.R., L.E.S.H., J.Y.S., J.F.F.)
- Faculty of Medicine, The University of Queensland, Brisbane, Australia (L.E.S.H., J.Y.S., J.F.F.)
| | - Xiaoli Chen
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
| | - Yuliangzi Sun
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Australia (M.A.R., L.E.S.H., J.Y.S., J.F.F.)
- Faculty of Medicine, The University of Queensland, Brisbane, Australia (L.E.S.H., J.Y.S., J.F.F.)
| | - Robert J Hatch
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia (R.J.H., B.R., S.M., S.P.)
| | - Ben Rollo
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia (R.J.H., B.R., S.M., S.P.)
| | - Di Xia
- Genome Innovation Hub (D.X.), The University of Queensland, St Lucia, Australia
| | - Mubarak A H Alzubaidi
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
| | - Snezana Maljevic
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia (R.J.H., B.R., S.M., S.P.)
| | | | - James E Hudson
- QIMR Berghofer Medical Research Institute, Brisbane, Australia (G.A.Q.-R., J.E.H.)
| | - Enzo R Porrello
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Australia (E.R.P.)
- Department of Anatomy and Physiology, School of Biomedical Sciences, The University of Melbourne, Parkville, Australia (E.R.P.)
| | - Melanie Y White
- School of Medical Sciences, School of Life and Environmental Sciences, and Charles Perkins Centre, The University of Sydney, Sydney, Australia (M.Y.W., S.J.C.)
| | - Stuart J Cordwell
- School of Medical Sciences, School of Life and Environmental Sciences, and Charles Perkins Centre, The University of Sydney, Sydney, Australia (M.Y.W., S.J.C.)
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Australia (M.A.R., L.E.S.H., J.Y.S., J.F.F.)
- Faculty of Medicine, The University of Queensland, Brisbane, Australia (L.E.S.H., J.Y.S., J.F.F.)
| | - Steven Petrou
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia (R.J.H., B.R., S.M., S.P.)
| | - Melissa E Reichelt
- School of Biomedical Sciences (Y.Y., M.E.R., W.G.T.), The University of Queensland, St Lucia, Australia
| | - Walter G Thomas
- School of Biomedical Sciences (Y.Y., M.E.R., W.G.T.), The University of Queensland, St Lucia, Australia
| | - Glenn F King
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Science (N.J.S., G.F.K.), The University of Queensland, St Lucia, Australia
| | - Peter S Macdonald
- Victor Chang Cardiac Research Institute, Sydney, Australia (S.E.S., L.G., M.H., J.E.V., Y.J., P.S.M.)
- Cardiopulmonary Transplant Unit (S.E.S., Y.J., P.S.M.), St Vincent's Hospital, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia (S.E.S., M.H., J.E.V., Y.J., P.S.M.)
| | - Nathan J Palpant
- Institute for Molecular Bioscience (M.A.R., N.J.S., H.S.C., C.Y.C., X.C., Y.S., M.A.H.A., G.F.K., N.J.P.), The University of Queensland, St Lucia, Australia
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28
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Anguela-Calvet L, Moreno-Gonzalez G, Sbraga F, Gonzalez-Costello J, Tsui S, Oliver-Juan E. Heart Donation From Donors After Controlled Circulatory Death. Transplantation 2021; 105:1482-1491. [PMID: 33208694 DOI: 10.1097/tp.0000000000003545] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The gold-standard therapy for advanced-stage heart failure is cardiac transplantation. Since the first heart transplant in 1967, the majority of hearts transplanted came from brain death donors. Nevertheless, in recent years, the option of donation after circulatory death (DCD) is gaining importance to increase donor pool. Currently, heart-transplant programs using controlled donation after circulatory death (cDCD) have been implemented in the United Kingdom, Belgium, Australia, United States of America, and, recently, in Spain. In this article, we performed a concise review of the literature in heart cDCD; we summarize the pathophysiology involved in ischemia and reperfusion injury during this process, the different techniques of heart retrieval in cDCD donors, and the strategies that can be used to minimize the damage during retrieval and until transplantation. Heart transplant using DCD hearts is in continuous improvement and must be implemented in experienced cardiac transplant centers.
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Affiliation(s)
- Laura Anguela-Calvet
- Intensive Care Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Transplant Procurement Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Gabriel Moreno-Gonzalez
- Intensive Care Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Transplant Procurement Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Fabrizio Sbraga
- Cardiac Surgery Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Jose Gonzalez-Costello
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Advance Heart Failure and Cardiac Transplantation Unit, Cardiology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Steven Tsui
- Cardiothoracic Surgery Department, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Eva Oliver-Juan
- Intensive Care Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Transplant Procurement Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
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29
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Villanueva JE, Chew HC, Gao L, Doyle A, Scheuer SE, Hicks M, Jabbour A, Dhital KK, Macdonald PS. The Effect of Increasing Donor Age on Myocardial Ischemic Tolerance in a Rodent Model of Donation After Circulatory Death. Transplant Direct 2021; 7:e699. [PMID: 34036169 PMCID: PMC8133134 DOI: 10.1097/txd.0000000000001148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/19/2021] [Indexed: 01/16/2023] Open
Abstract
Hearts from older donors or procured via donation after circulatory death (DCD) can alleviate transplant waitlist; however, these hearts are particularly vulnerable to injury caused by warm ischemic times (WITs) inherent to DCD. This study investigates how the combination of increasing donor age and pharmacologic supplementation affects the ischemic tolerance and functional recovery of DCD hearts and how age impacts cardiac mitochondrial respiratory capacity and oxidative phosphorylation.
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Affiliation(s)
- Jeanette E Villanueva
- Physiology and Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, University of New South Wales Sydney, Randwick, NSW, Australia
| | - Hong C Chew
- Physiology and Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Ling Gao
- Physiology and Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Aoife Doyle
- Physiology and Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Sarah E Scheuer
- Physiology and Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, University of New South Wales Sydney, Randwick, NSW, Australia
| | - Mark Hicks
- Physiology and Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Andrew Jabbour
- Physiology and Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, University of New South Wales Sydney, Randwick, NSW, Australia.,Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Kumud K Dhital
- Physiology and Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Peter S Macdonald
- Physiology and Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, University of New South Wales Sydney, Randwick, NSW, Australia.,Heart and Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia
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30
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Scheuer SE, Jansz PC, Macdonald PS. Heart transplantation following donation after circulatory death: Expanding the donor pool. J Heart Lung Transplant 2021; 40:882-889. [PMID: 33994229 DOI: 10.1016/j.healun.2021.03.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022] Open
Abstract
Heart transplantation from donation after circulatory death (DCD) donors is a rapidly expanding practice. In this review, we describe the history and challenges of DCD heart transplantation and overview the procurement protocols and methods of limiting ischemic injury, current outcomes, and future directions. There are now at least three protocols that permit resuscitation and viability assessment of the DCD heart either in situ or ex situ. While the retrieval protocol for hearts from DCD donors will depend on local regulations, the outcomes of DCD heart transplant recipients reported to date are excellent regardless of the retrieval protocol and are comparable to the outcomes of heart transplant recipients from donation after brain death (DBD) donors. In the two centers with the largest published experience, DCD heart transplantation now accounts for one third of their heart transplant activity. With international trends indicating that there is an increasing utilisation of the DCD pathway, it is expected that DCD donors will become a major source of heart donation worldwide.
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Affiliation(s)
- Sarah E Scheuer
- Cardiac Physiology & Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; Heart & Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Randwick, Australia
| | - Paul C Jansz
- Cardiac Physiology & Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; Heart & Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Randwick, Australia
| | - Peter S Macdonald
- Cardiac Physiology & Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; Heart & Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Randwick, Australia.
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31
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Tong CKW, Khush KK. New Approaches to Donor Selection and Preparation in Heart Transplantation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021; 23:28. [PMID: 33776401 PMCID: PMC7985579 DOI: 10.1007/s11936-021-00906-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 02/06/2023]
Abstract
Purpose of review With increasing survival of patients with stage D heart failure, the demand for heart transplantation has increased. The supply of donor hearts remains relatively limited. Strategies have been investigated and new technologies have been developed to expand the current donor pool. These new approaches will be discussed herein. Recent findings Donor hearts are often considered “marginal” due to risk factors such as older age, size mismatch with the intended recipient, prolonged ischemic time, presence of left ventricular hypertrophy, and hepatitis B/C infection. We reviewed recent data regarding the use of donor hearts with these risk factors and suggest ways to safely liberalize current donor heart acceptance criteria. New technologies such as temperature-controlled transport systems and ex vivo cardiac perfusion methods have also demonstrated promising short-term and intermediate outcomes as compared with routine cold storage, by promoting heart preservation and enabling heart procurement from remote sites with shorter cold ischemic time. Recent use of hearts from donation after circulatory death donors has demonstrated comparable outcomes to conventional donation after brain death, which can further expand the current donor pool. Summary Careful selection of “marginal” donor hearts, use of ex vivo cardiac perfusion, and acceptance of hearts after circulatory death may expand our current cardiac donor pool with comparable outcomes to conventional donor selection and preparation methods.
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Affiliation(s)
- Calvin K W Tong
- Cardiovascular Medicine, Stanford University, 300 Pasteur Drive, Falk CVRC 263, Stanford, CA 94305 USA
| | - Kiran K Khush
- Cardiovascular Medicine, Stanford University, 300 Pasteur Drive, Falk CVRC 263, Stanford, CA 94305 USA
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32
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Vandendriessche K, Tchana-Sato V, Ledoux D, Degezelle K, Rex S, Neyrinck A, Jochmans I, Monbaliu D, Vandenbriele C, Cleemput JV, Meyns B, Rega F. Transplantation of donor hearts after circulatory death using normothermic regional perfusion and cold storage preservation. Eur J Cardiothorac Surg 2021; 60:813-819. [PMID: 33783513 DOI: 10.1093/ejcts/ezab139] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/01/2021] [Accepted: 02/08/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Hearts donated after circulatory determination of death are usually preserved with normothermic machine perfusion prior to transplantation. This type of preservation is costly, requires bench time adding to warm ischaemia, and does not provide a reliable evaluation of the unloaded donor heart. We report on 4 successful donation after circulatory death (category III) hearts transplanted after thoraco-abdominal normothermic regional perfusion (NRP) and static cold storage. METHODS After life sustaining therapy was withdrawn and death was declared, perfusion to thoraco-abdominal organs was restored using extracorporeal circulation via cannulas in the femoral artery and vein and clamping of supra-aortic vessels. After weaning from extracorporeal circulation, cardiac function was assessed. Once approved, the heart was retrieved and stored using classic static cold storage. Data are expressed as median [min-max]. RESULTS Donor and recipient ages were 44 years [12-60] (n = 4) and 53 years [14-64] (n = 4), respectively. Time from the withdrawal of life sustaining therapy to start of NRP was 22 min [18-31]. Cold storage time was 72 min [35-129]. Thirty-day survival was 100% with a left ventricle ejection fraction of 60% [50-60]. CONCLUSIONS Donation after circulatory death heart transplantation using thoraco-abdominal NRP and subsequent cold storage preservation for up to 129 min was safe for 4 procedures and could be a way to expand the donor heart pool while avoiding costs of machine preservation.
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Affiliation(s)
- Katrien Vandendriessche
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Vincent Tchana-Sato
- Department of Cardiothoracic Surgery, University Hospital Liège, Liege, Belgium
| | - Didier Ledoux
- Department of Anesthesiology and Intensive Care, University Hospital Liège, Liege, Belgium
| | - Karlien Degezelle
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Abdominal Transplantation, University Hospitals Leuven, Leuven, Belgium.,Transplant Research Group, Department of Microbiology, Immunology, and Transplantation, Catholic University Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplantation, University Hospitals Leuven, Leuven, Belgium.,Transplant Research Group, Department of Microbiology, Immunology, and Transplantation, Catholic University Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Van Cleemput
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
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33
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Castillo-Angeles M, Li G, Bain PA, Stinebring J, Salim A, Adler JT. Systematic review of hospital-level metrics and interventions to increase deceased organ donation. Transplant Rev (Orlando) 2021; 35:100613. [PMID: 33744820 DOI: 10.1016/j.trre.2021.100613] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/03/2021] [Accepted: 03/03/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Efforts to ameliorate the organ shortage have predominantly focused on improving processes and interventions at multiple levels in the organ donation process, but no comprehensive review of hospital-level features contributing to organ donation exists. We undertook a systematic review of the literature to better understand current knowledge and knowledge gaps about hospital-level metrics and interventions associated with successful organ donation. METHODS We searched six electronic databases (PubMed, Embase, CINAHL, Web of Science, Health Business Elite, and Google scholar) and conference abstracts for articles on hospital-level features associated with the final outcome of organ donation (PROSPERO CRD42020187080). Editorials, letters to the editor, and reviews without original data were excluded. Our main outcomes were conversion rate, donation rate, number of organs recovered, number of donors, and authorization rate. RESULTS Our search yielded 2177 studies, and after a thorough assessment, 72 articles were included in this systematic review. Studies were thematically categorized into 1) Hospital-level interventions associated with metrics of organ donation; these included patient- and family-centric measures (i.e. standardized interviews, collaborative requesting and decoupling, and dedicated in-house coordinators), and donor management goals that significantly increased conversion rates by up to 64%; 2) Hospital-level multi-stage programs/policies; which increased authorization rates between 30 and 50%; and 3) Hospital characteristics and qualities; being an academic center, trauma center and larger hospital correlated with higher authorization and conversion rates. Most studies had considerable risk of bias and were of low quality. CONCLUSIONS There is a lack of well-designed studies on hospital-level metrics and interventions associated with organ donation. The use of thoughtful, patient- and family-centric approaches to authorization generally is associated with more organ donors. Future work can build on what is known about the hospital role in organ donation to improve the entire organ donation process.
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Affiliation(s)
- Manuel Castillo-Angeles
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America
| | - George Li
- Brandeis University, Waltham, MA, United States of America
| | - Paul A Bain
- Countway Library, Harvard Medical School, Boston, MA, United States of America
| | - Jill Stinebring
- New England Donor Services, Waltham, MA, United States of America
| | - Ali Salim
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Joel T Adler
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Transplantation, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America.
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34
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Wells MA, See Hoe LE, Heather LC, Molenaar P, Suen JY, Peart J, McGiffin D, Fraser JF. Peritransplant Cardiometabolic and Mitochondrial Function: The Missing Piece in Donor Heart Dysfunction and Graft Failure. Transplantation 2021; 105:496-508. [PMID: 33617201 DOI: 10.1097/tp.0000000000003368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Primary graft dysfunction is an important cause of morbidity and mortality after cardiac transplantation. Donor brain stem death (BSD) is a significant contributor to donor heart dysfunction and primary graft dysfunction. There remain substantial gaps in the mechanistic understanding of peritransplant cardiac dysfunction. One of these gaps is cardiac metabolism and metabolic function. The healthy heart is an "omnivore," capable of utilizing multiple sources of nutrients to fuel its enormous energetic demand. When this fails, metabolic inflexibility leads to myocardial dysfunction. Data have hinted at metabolic disturbance in the BSD donor and subsequent heart transplantation; however, there is limited evidence demonstrating specific metabolic or mitochondrial dysfunction. This review will examine the literature surrounding cardiometabolic and mitochondrial function in the BSD donor, organ preservation, and subsequent cardiac transplantation. A more comprehensive understanding of this subject may then help to identify important cardioprotective strategies to improve the number and quality of donor hearts.
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Affiliation(s)
- Matthew A Wells
- School of medical Science, Griffith University Gold Coast, Australia
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Australia
| | - Louise E See Hoe
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Australia
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, St Lucia, Australia
| | - Lisa C Heather
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Peter Molenaar
- Faculty of Health, School of Biomedical Sciences, Queensland University of Technology, Brisbane City, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Australia
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, St Lucia, Australia
| | - Jason Peart
- School of medical Science, Griffith University Gold Coast, Australia
| | - David McGiffin
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Australia
- Cardiothoracic Surgery and Transplantation, The Alfred Hospital, Melbourne, Australia
| | - John F Fraser
- School of medical Science, Griffith University Gold Coast, Australia
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Australia
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, St Lucia, Australia
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35
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Wyss RK, Méndez Carmona N, Arnold M, Segiser A, Mueller M, Dutkowski P, Carrel TP, Longnus SL. Hypothermic, oxygenated perfusion (HOPE) provides cardioprotection via succinate oxidation prior to normothermic perfusion in a rat model of donation after circulatory death (DCD). Am J Transplant 2021; 21:1003-1011. [PMID: 32786170 DOI: 10.1111/ajt.16258] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 01/25/2023]
Abstract
In donation after circulatory death (DCD), cardiac grafts are subjected to warm ischemia in situ, prior to a brief period of cold, static storage (CSS) at procurement, and ex situ, normothermic, machine perfusion (NMP) for transport and graft evaluation. Cold ischemia and normothermic reoxygenation during NMP could aggravate graft injury through continued accumulation and oxidation, respectively, of mitochondrial succinate, and the resultant oxidative stress. We hypothesized that replacing CSS with hypothermic, oxygenated perfusion (HOPE) could provide cardioprotection by reducing cardiac succinate levels before NMP. DCD was simulated in male Wistar rats. Following 21 minutes in situ ischemia, explanted hearts underwent 30 minutes hypothermic storage with 1 of the following: (1) CSS, (2) HOPE, (3) hypothermic deoxygenated perfusion (HNPE), or (4) HOPE + AA5 (succinate dehydrogenase inhibitor) followed by normothermic reperfusion to measure cardiac and metabolic recovery. After hypothermic storage, tissue ATP/ADP levels were higher and succinate concentration was lower in HOPE vs CSS, HNPE, and HOPE + AA5 hearts. After 60 minutes reperfusion, cardiac function was increased and cellular injury was decreased in HOPE compared with CSS, HNPE, and HOPE + AA5 hearts. HOPE provides improved cardioprotection via succinate oxidation prior to normothermic reperfusion compared with CSS, and therefore is a promising strategy for preservation of cardiac grafts obtained with DCD.
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Affiliation(s)
- Rahel K Wyss
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Natalia Méndez Carmona
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Maria Arnold
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Adrian Segiser
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Matteo Mueller
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Sarah L Longnus
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
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36
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Ex Situ Perfusion of Hearts Donated After Euthanasia: A Promising Contribution to Heart Transplantation. Transplant Direct 2021; 7:e676. [PMID: 34104712 PMCID: PMC8183709 DOI: 10.1097/txd.0000000000001120] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/09/2020] [Accepted: 11/30/2020] [Indexed: 12/13/2022] Open
Abstract
Organ donation after euthanasia is performed in an increasing number of countries. In this donation after circulatory death procedure, it has not been possible to donate the heart. Recent literature, however, reports positive results of heart donation after circulatory death. Therefore, patients who donate organs following euthanasia might be suitable candidates for heart donation. We want to confirm this assumption by sharing the results of 2 cases of heart donation following euthanasia with ex situ subnormothermic heart preservation. Our aim is to raise awareness of the potential of heart donation following euthanasia for both clinical transplantation and research. Methods The data of 2 consecutive heart donations following euthanasia were collected prospectively. Informed consent was obtained from the patients themselves for heart donation for research purposes. An acellular oxygenated subnormothermic machine perfusion strategy was used to preserve both donor hearts. Subsequently, the hearts were evaluated on a normothermic perfusion machine using a balloon in the left ventricle. Results Heart donation following euthanasia was feasible without significant changes in existing retrieval protocols. Duration of machine perfusion preservation was 408 and 432 minutes, for heart 1 and 2, respectively. For heart 1, developed pressure (Pdev) was 119 mm Hg, maximal rate of pressure rise (dP/dtmax), and fall (dP/dtmin) were 1524 mm Hg/s and -1057 mm Hg/s, respectively. For heart 2, Pdev was 142 mm Hg, dP/dtmax was 1098 mm Hg/s, and dP/dtmin was -802 mm Hg/s. Conclusions Hearts donated following euthanasia are highly valuable for research purposes and can have sufficient quality to be transplanted. With the implementation of ex situ heart perfusion, patients who are to donate their organs following euthanasia should also be able to donate their hearts. The complex combination of euthanasia and heart donation is ethically sound and surgically feasible and can contribute to shortening the heart transplant waiting list.
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37
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Heart Transplantation From Brain Dead Donors: A Systematic Review of Animal Models. Transplantation 2021; 104:2272-2289. [PMID: 32150037 DOI: 10.1097/tp.0000000000003217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Despite advances in mechanical circulatory devices and pharmacologic therapies, heart transplantation (HTx) is the definitive and most effective therapy for an important proportion of qualifying patients with end-stage heart failure. However, the demand for donor hearts significantly outweighs the supply. Hearts are sourced from donors following brain death, which exposes donor hearts to substantial pathophysiological perturbations that can influence heart transplant success and recipient survival. Although significant advances in recipient selection, donor and HTx recipient management, immunosuppression, and pretransplant mechanical circulatory support have been achieved, primary graft dysfunction after cardiac transplantation continues to be an important cause of morbidity and mortality. Animal models, when appropriate, can guide/inform medical practice, and fill gaps in knowledge that are unattainable in clinical settings. Consequently, we performed a systematic review of existing animal models that incorporate donor brain death and subsequent HTx and assessed studies for scientific rigor and clinical relevance. Following literature screening via the U.S National Library of Medicine bibliographic database (MEDLINE) and Embase, 29 studies were assessed. Analysis of included studies identified marked heterogeneity in animal models of donor brain death coupled to HTx, with few research groups worldwide identified as utilizing these models. General reporting of important determinants of heart transplant success was mixed, and assessment of posttransplant cardiac function was limited to an invasive technique (pressure-volume analysis), which is limitedly applied in clinical settings. This review highlights translational challenges between available animal models and clinical heart transplant settings that are potentially hindering advancement of this field of investigation.
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38
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Bona M, Wyss RK, Arnold M, Méndez-Carmona N, Sanz MN, Günsch D, Barile L, Carrel TP, Longnus SL. Cardiac Graft Assessment in the Era of Machine Perfusion: Current and Future Biomarkers. J Am Heart Assoc 2021; 10:e018966. [PMID: 33522248 PMCID: PMC7955334 DOI: 10.1161/jaha.120.018966] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Heart transplantation remains the treatment of reference for patients experiencing end‐stage heart failure; unfortunately, graft availability through conventional donation after brain death is insufficient to meet the demand. Use of extended‐criteria donors or donation after circulatory death has emerged to increase organ availability; however, clinical protocols require optimization to limit or prevent damage in hearts possessing greater susceptibility to injury than conventional grafts. The emergence of cardiac ex situ machine perfusion not only facilitates the use of extended‐criteria donor and donation after circulatory death hearts through the avoidance of potentially damaging ischemia during graft storage and transport, it also opens the door to multiple opportunities for more sensitive monitoring of graft quality. With this review, we aim to bring together the current knowledge of biomarkers that hold particular promise for cardiac graft evaluation to improve precision and reliability in the identification of hearts for transplantation, thereby facilitating the safe increase in graft availability. Information about the utility of potential biomarkers was categorized into 5 themes: (1) functional, (2) metabolic, (3) hormone/prohormone, (4) cellular damage/death, and (5) inflammatory markers. Several promising biomarkers are identified, and recommendations for potential improvements to current clinical protocols are provided.
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Affiliation(s)
- Martina Bona
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Rahel K Wyss
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Maria Arnold
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Natalia Méndez-Carmona
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Maria N Sanz
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Dominik Günsch
- Department of Anesthesiology and Pain Medicine/Institute for Diagnostic, Interventional and Paediatric Radiology Bern University HospitalInselspitalUniversity of Bern Switzerland
| | - Lucio Barile
- Laboratory for Cardiovascular Theranostics Cardiocentro Ticino Foundation and Faculty of Biomedical Sciences Università Svizzera Italiana Lugano Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Sarah L Longnus
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
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39
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Mariager CØ, Hansen ESS, Bech SK, Eiskjaer H, Nielsen PF, Ringgaard S, Kimose HH, Laustsen C. Development of a human heart-sized perfusion system for metabolic imaging studies using hyperpolarized [1- 13 C]pyruvate MRI. Magn Reson Med 2020; 85:3510-3521. [PMID: 33368597 DOI: 10.1002/mrm.28639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/09/2020] [Accepted: 11/19/2020] [Indexed: 11/09/2022]
Abstract
PURPOSE Increasing worldwide demand for cardiac transplantation has spurred new developments to increase the donor pool. Normothermic preservation of heart grafts for transplantation is an emerging strategy to improve the utilization of marginal grafts. Hyperpolarized MR using metabolic tracers such as [1-13 C]pyruvate, provide a novel means of investigating metabolic status without the use of ionizing radiation. We demonstrate the use of this methodology to examine ex vivo perfused porcine heart grafts. METHODS Hearts from three 40-kg Danish domestic pigs were harvested and subsequently perfused in Langendorff mode under normothermic conditions, using an MR-compatible perfusion system adapted to the heart. Proton MRI and hyperpolarized [1-13 C]pyruvate were used to investigate and quantify the functional and metabolic status of the grafts. RESULTS Hearts were perfused with whole blood for 120 min, using a dynamic contrast-enhanced perfusion experiment to verify successful myocardial perfusion. Hyperpolarized [1-13 C]pyruvate MRI was used to assess the metabolic state of the myocardium. Functional assessment was performed using CINE imaging and ventricular pressure data. High lactate and modest alanine levels were observed in the hyperpolarized experiment. The functional assessment produced reduced functional parameters. This suggests an altered functional and metabolic profile compared with corresponding in vivo values. CONCLUSION We investigated the metabolic and functional status of machine-perfused porcine hearts. Utilizing hyperpolarized methodology to acquire detailed myocardial metabolic information-in combination with already established MR methods for cardiac investigation-provides a powerful tool to aid the progress of donor heart preservation.
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Affiliation(s)
| | | | - Sabrina Kahina Bech
- Department of Clinical Medicine, MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Hans Eiskjaer
- Department of Clinical Medicine, Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Fast Nielsen
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen Ringgaard
- Department of Clinical Medicine, MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Hans-Henrik Kimose
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Christoffer Laustsen
- Department of Clinical Medicine, MR Research Centre, Aarhus University, Aarhus, Denmark
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Kobayashi Y, Kotani Y, Sakoda N, Kadowaki S, Kasahara S. Ex vivo evaluation of the biventricular cardiac function for donation after circulatory death model: An experimental study. Artif Organs 2020; 45:373-381. [PMID: 33001457 DOI: 10.1111/aor.13834] [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: 07/07/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 11/29/2022]
Abstract
Few reports on a biventricular working heart model with ex vivo perfusion exist owing to the complexity of establishing a circuit. Hence, we investigated it for donation after circulatory death. The heart in six juvenile pigs (~20 kg) was arrested by asphyxiation. After 30 minutes of global ischemia, the heart was harvested, reperfused with normoxemic blood cardioplegia for 20 minutes, and subsequently perfused with hyperxemic blood. After 70 minutes of controlled reperfusion, the system was switched to the biventricular working mode. Cardiac function was assessed before anoxia and during the biventricular mode. Left and right ventricular functions worsened during the biventricular mode, as compared to those before anoxia (dP/dtmax , 673 ± 120 vs. 283 ± 95 and 251 ± 35 vs. 141 ± 21 mm Hg/s, respectively; P < .001). Systemic (resistance/100 g net heart weight) and pulmonary vascular resistance indexes during the biventricular mode were similar to those before anoxia (829 ± 262 vs. 759 ± 359, P = .707, and 167 ± 57 vs. 158 ± 83 dynes·sec·cm-5 - l-100-g net heart weight, P = .859, respectively). The biventricular working heart model with ex vivo perfusion was feasible, exhibited stable hemodynamics, and has the potential to be a powerful tool for direct cardiac function assessment.
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Affiliation(s)
- Yasuyuki Kobayashi
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Naoya Sakoda
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Sachiko Kadowaki
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Platelet activation after withdrawal of life support in donation after circulatory death donors. J Heart Lung Transplant 2020; 39:1494-1496. [DOI: 10.1016/j.healun.2020.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 11/21/2022] Open
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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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Dhital K, Ludhani P, Scheuer S, Connellan M, Macdonald P. DCD donations and outcomes of heart transplantation: the Australian experience. Indian J Thorac Cardiovasc Surg 2020; 36:224-232. [PMID: 33061207 DOI: 10.1007/s12055-020-00998-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/13/2020] [Accepted: 06/23/2020] [Indexed: 12/19/2022] Open
Abstract
Purpose There is increasing clinical utilization of hearts from the donation after circulatory death (DCD) pathway with the aim of expanding the donor pool and mitigating the ever-present discrepancy between the inadequate availability of good quality donor hearts and the rising number of patients with end-stage heart failure. Methods This article reviews the rationale, practice, logistical factors, and 5-year experience of DCD heart transplantation at St Vincent's Hospital, Sydney. Findings Between July 2014 and July 2019, 69 DCD donor retrievals were undertaken resulting in 49 hearts being instrumented on an ex situ normothermic cardiac perfusion device. Seventeen (35%) of these hearts were declined and the remaining 32 (65%) were used for orthotopic DCD heart transplantation. At 5 years of follow-up, the 1-, 3-, and 5-year survival was 96%, 94%, and 94% for DCD hearts compared with 89%, 83%, and 82% respectively for donation after brain death (DBD) hearts (n.s). The immediate post-implant requirement for temporary extra-corporeal membrane oxygenation (ECMO) support for delayed graft function was 31% with no difference in rejection rates when compared with the contemporaneous cohort of patients transplanted with standard criteria DBD hearts. Summary DCD heart transplantation has become routine and incorporated into standard clinical practice by a handful of pioneering clinical transplant centres. The Australian experience demonstrates that excellent medium-term outcomes are achievable from the use of DCD hearts. These outcomes are consistent across the other centres and consequently favour a more rapid and wider uptake of heart transplantation using DCD donor hearts, which would otherwise be discarded.
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Affiliation(s)
- Kumud Dhital
- Department of Cardiothoracic Surgery & Transplantation, Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004 Australia.,Transplant Laboratory, Victor Chang Cardiac Research Institute, Lowy Packer Building, 405 Liverpool St, Darlinghurst, NSW 2010 Australia
| | - Prakash Ludhani
- Department of Cardiothoracic Surgery, MIOT Hospital, Chennai, India
| | - Sarah Scheuer
- Transplant Laboratory, Victor Chang Cardiac Research Institute, Lowy Packer Building, 405 Liverpool St, Darlinghurst, NSW 2010 Australia.,Department of Cardiothoracic Surgery, St Vincent's Hospital, Darlinghurst, Sydney, NSW 2010 Australia
| | - Mark Connellan
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Darlinghurst, Sydney, NSW 2010 Australia
| | - Peter Macdonald
- Transplant Laboratory, Victor Chang Cardiac Research Institute, Lowy Packer Building, 405 Liverpool St, Darlinghurst, NSW 2010 Australia.,Department of Cardiothoracic Surgery, St Vincent's Hospital, Darlinghurst, Sydney, NSW 2010 Australia
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Oligonucleotide-based Preconditioning of DCD Cardiac Donors and Its Impact on Cardiac Viability. Transplantation 2020; 103:2479-2485. [PMID: 31335774 DOI: 10.1097/tp.0000000000002849] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While clinical donation after circulatory death (DCD) cardiac transplantation is being implemented with increasing frequency to address the supply/demand mismatch of donor grafts, no research to date has examined a strategy of donor preconditioning to optimize the viability of DCD hearts for transplantation. In our rat model of the DCD protocol, we investigate the impact of pretreating donors with phosphorothioate-linked cytosine and guanine rich oligodeoxynucleotides (CpG ODN) and their effects on cardiac function, injury, and a novel left ventricular (LV) mRNA biomarker panel. METHODS DCD rats were subjected to a withdrawal protocol, followed by 20 minutes of warm acirculatory standoff, representing a group of severely injured hearts as previously demonstrated. Beating heart controls and DCD rats were pretreated with vehicle or stimulatory CpG ODN (beating heart control and DCD stimulated with CpG ODN, BST and DST). Hearts were harvested for ex situ heart perfusion (ESHP), where LV function, histochemical injury, and differences in gene expression were characterized between groups. RESULTS Donor pretreatment with CpG ODN doubled the number of functional DCD hearts at ESHP. Pretreatment was associated with improved systolic and diastolic LV function, a reduction in histological injury, and markedly reduced elaboration of cardiac troponin-I in coronary effluent during ESHP. Pretreatment was also associated with a reduction in mRNA biomarkers associated with myocardial injury. CONCLUSIONS A single dose of CpG ODN was associated with reduced biomarkers of cardiac injury and a 100% increase in cardiac viability in this rodent model of marginal DCD cardiac donation.
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Abstract
PURPOSE OF REVIEW Increasing number of patients with end-stage heart failure and those with improved survivorship from selective utilization of implantable mechanical circulatory support devices have added further burden and complexity to the transplant waitlist and on the rate-limiting availability of donor hearts from the standard pathway of donation after brain death. Unlike this conventional route, the increasing clinical use of donation after circulatory death (DCD) donor hearts necessitates a closer understanding of the logistics involved in the DCD process as well as of the risks associated with the unique pathophysiological consequences in this setting. RECENT FINDINGS Notwithstanding a higher incidence of delayed graft function, the clinical utilization of DCD hearts for cardiac transplantation over the past five years has demonstrated this to be a well-tolerated and strategic alternative with excellent medium-term clinical outcomes. SUMMARY The uptake of DCD heart transplantation remains selective and currently confined to Australia, the United Kingdom, Belgium, and more recently the USA. A more significant adoption will only come about through: a concerted effort to resolve the ethical and clinical controversies; a better understanding of postconditioning strategies; continued resolve to reduce the obligatory period of warm ischemia; and from better extracorporeal platforms that permit functional viability assessment of the DCD donor heart.
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Saemann L, Guo Y, Ding Q, Zhou P, Karck M, Szabó G, Wenzel F. Machine perfusion of circulatory determined death hearts: A scoping review. Transplant Rev (Orlando) 2020; 34:100551. [PMID: 32498975 DOI: 10.1016/j.trre.2020.100551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/25/2020] [Accepted: 04/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ex vivo machine perfusion (EVMP) is reported to can successfully be applied for donor heart preservation. To respond to the organ shortage, some centres also accept hearts from marginal donors such as non-heart beating donors (NHBD) or hearts donated after cardiac death (DCD) for heart transplantation (HTx). Clinical as well as preclinical science on EVMP of DCD hearts seems to be promising but the ideal perfusion practice itself appears unclear. OBJECTIVES In accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA), this systematic review scopes all EVMP techniques for human and animal DCD heart preservation and addresses three specific questions, which refer to (a) the perfusion solutions, (b) the perfusion parameters and respective target values and (c) if possible, a direct comparison between cold static storage (CSS) and EVMP. RESULTS Search results predominantly consisted of animal studies. Either perfusion with a crystalloid or blood-based solution, each with cardioplegic or non-cardioplegic properties was used. Some perfusates were supplemented with specific pharmacological medication to block pathophysiological pathways, which are involved in ischemia/reperfusion injury or edema formation. Besides normothermic EVMP with oxygenated blood, a wide range of temperature was applied in all approaches, with the lowest temperature at 4 °C. Pressure controlled anterograde Langendorff perfusion was applied mostly. If investigated, crystalloid machine perfusion was presented superior to CSS. CONCLUSIONS Only blood based EVMP was introduced into clinical practice. More research, clinical as well as preclinical, is needed to develop the ideal EVMP technique, in terms of blood or crystalloid perfusion.
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Affiliation(s)
- Lars Saemann
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany; Faculty Medical and Life Sciences, Furtwangen University, Jakob-Kienzle-Straße 17, Villingen-Schwenningen 78054, Germany.
| | - Yuxing Guo
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Qingwei Ding
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Pengyu Zhou
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Gábor Szabó
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Folker Wenzel
- Faculty Medical and Life Sciences, Furtwangen University, Jakob-Kienzle-Straße 17, Villingen-Schwenningen 78054, Germany.
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Niederberger P, Farine E, Raillard M, Dornbierer M, Freed DH, Large SR, Chew HC, MacDonald PS, Messer SJ, White CW, Carrel TP, Tevaearai Stahel HT, Longnus SL. Heart Transplantation With Donation After Circulatory Death. Circ Heart Fail 2020; 12:e005517. [PMID: 30998395 DOI: 10.1161/circheartfailure.118.005517] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Heart transplantation remains the preferred option for improving quality of life and survival for patients suffering from end-stage heart failure. Unfortunately, insufficient supply of cardiac grafts has become an obstacle. Increasing organ availability with donation after circulatory death (DCD) may be a promising option to overcome the organ shortage. Unlike conventional donation after brain death, DCD organs undergo a period of warm, global ischemia between circulatory arrest and graft procurement, which raises concerns for graft quality. Nonetheless, the potential of DCD heart transplantation is being reconsidered, after reports of more than 70 cases in Australia and the United Kingdom over the past 3 years. Ensuring optimal patient outcomes and generalized adoption of DCD in heart transplantation, however, requires further development of clinical protocols, which in turn require a better understanding of cardiac ischemia-reperfusion injury and the various possibilities to limit its adverse effects. Thus, we aim to provide an overview of the knowledge obtained with preclinical studies in animal models of DCD heart transplantation, to facilitate and promote the most effective and efficient advancement in preclinical research. A literature search of the PubMed database was performed to identify all relevant preclinical studies in DCD heart transplantation. Specific aspects relevant for DCD heart transplantation were analyzed, including animal models, graft procurement and storage conditions, cardioprotective approaches, and graft evaluation strategies. Several potential therapeutic strategies for optimizing graft quality are identified, and recommendations for further preclinical research are provided.
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Affiliation(s)
- Petra Niederberger
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Emilie Farine
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Mathieu Raillard
- Experimental Surgery Unit (ESI), Experimental Surgery Unit, Department for BioMedical Research and Vetsuisse Faculty, Department of Clinical Veterinary Medicine, Institute of Anaesthesiology and Pain Therapy, University of Bern, Switzerland (M.R.)
| | - Monika Dornbierer
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Darren H Freed
- Cardiac Surgery, University of Alberta, Edmonton, Canada (D.H.F., C.W.W.)
| | - Stephen R Large
- Department of Transplantation, Royal Papworth Hospital, Papworth Everard, Cambridge, United Kingdom (S.R.L., S.J.M.)
| | - Hong C Chew
- St Vincent's Hospital, University of New South Wales, Victor Chang Cardiac Research Institute, Sydney, Australia (H.C.C., P.S.M.)
| | - Peter S MacDonald
- St Vincent's Hospital, University of New South Wales, Victor Chang Cardiac Research Institute, Sydney, Australia (H.C.C., P.S.M.)
| | - Simon J Messer
- Department of Transplantation, Royal Papworth Hospital, Papworth Everard, Cambridge, United Kingdom (S.R.L., S.J.M.)
| | | | - Thierry P Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Hendrik T Tevaearai Stahel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Sarah L Longnus
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
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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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Flow-targeted pediatric ex vivo heart perfusion in donation after circulatory death: A porcine model. J Heart Lung Transplant 2019; 39:267-277. [PMID: 31892427 DOI: 10.1016/j.healun.2019.11.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/31/2019] [Accepted: 11/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The optimal blood flow and pressure to perfuse pediatric hearts from donation after circulatory death (DCD) on the ex vivo perfusion system has not been elucidated. This study sought to investigate the optimal perfusion strategy for pediatric DCD hearts by using a juvenile porcine model comparing pressure- vs flow-targeted strategy. METHODS The hearts of the juvenile DCD pigs were explanted, and the coronary arteries were perfused for 2 hours by the ex vivo heart perfusion system with 2 different perfusion strategies; pressure-targeted perfusion (target coronary perfusion pressure: 40 mm Hg, group A) and flow-targeted perfusion (target coronary perfusion flow: 10 ml/kg/min, group B). The working model heart perfusion was used to assess systolic and diastolic myocardial performance. RESULTS The body weight, warm and cold ischemic time, and ex vivo perfusion time were comparable between the groups. In the working model, group B showed significantly preserved cardiac output (A: 70.5 ± 15.3 ml/kg/min vs B: 113.8 ± 15.0 ml/kg/min, p < 0.01), stroke volume (A: 0.4 ± 0.1 ml/kg vs B: 0.7 ± 0.1 ml/kg, p < 0.01), and ejection fraction (A: 18.8% ± 5.9% vs B: 35.0% ± 10.6%, p < 0.01). E/e' and Tei index were also significantly preserved in group B. The percentage gain of heart weight after ex vivo (net increase of the heart weight divided by heart weight at baseline) was significantly smaller in group B (A: 20.0% ± 5.3% vs B: 11.6% ± 5.0%, p < 0.05). Troponin-I, myocardial hemorrhage, oxidative stress markers; myeloperoxidase and 8-hydroxy-2'-deoxyguanosine were also significantly lower after ex vivo perfusion in group B (p < 0.05). CONCLUSIONS The tightly controlled flow-targeted myocardial perfusion strategy for DCD donor hearts achieved better myocardial performance by causing less myocardial edema and limiting myocardial reperfusion injury.
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Abstract
Injuries sustained by donor heart and lung allografts during the transplantation process are multiple and cumulative. Optimization of allograft function plays an essential role in short- and long-term outcomes after transplantation. Therapeutic targets to prevent or attenuate injury are present in the donor, the preservation process, during transplantation, and in postoperative management of the recipient. The newest and most promising methods of optimizing donor heart and lung allografts are found in alternative preservation strategies, which enable functional assessment of donor organs and provide a modality to initiate therapies for injured allografts or prevent injury during reperfusion in recipients.
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Affiliation(s)
- Sue A Braithwaite
- Department of Anesthesiology, University Medical Center Utrecht, Mail Stop Q04.2.317, Postbus 85500, Utrecht 3508 GA, The Netherlands.
| | - Niels P van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Room E03.511, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
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