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Pradegan N, Di Pasquale L, Di Perna D, Gallo M, Lucertini G, Gemelli M, Beyerle T, Slaughter MS, Gerosa G. Ex vivo heart perfusion: an updated systematic review. Heart Fail Rev 2024; 29:1079-1096. [PMID: 39093495 DOI: 10.1007/s10741-024-10420-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2024] [Indexed: 08/04/2024]
Abstract
Due to the discrepancy between patients awaiting a heart transplant and the availability of donor hearts, strategies to expand the donor pool and improve the transplant's success are crucial. This review aims to summarize current knowledge on the ex vivo heart preservation (EVHP) experience as an alternative to standard cold static storage (CSS). EVHP techniques can improve the preservation of the donor's heart before transplantation and allow for pre-transplant organ evaluation.
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Affiliation(s)
- Nicola Pradegan
- Cardiac Surgery Unit, Cardio-thoraco-vascular and Public Health Department, Padova University Hospital, Padua, Italy
| | - Luigi Di Pasquale
- Division of Congenital Cardiovascular Surgery, Pediatric Heart Centre and Children's Research Centre, University Children's Hospital Zürich, Zurich, Switzerland
| | - Dario Di Perna
- Centre Hospitalier Annecy Genevois, Épagny-Metz-Tessy, France
| | - Michele Gallo
- Department of Cardiothoracic Surgery, University of Louisville, 201 Abraham Flexner Way, Suite 1200, Louisville, KY, 40202, USA.
| | - Giovanni Lucertini
- Cardiac Surgery Unit, Cardio-thoraco-vascular and Public Health Department, Padova University Hospital, Padua, Italy
| | - Marco Gemelli
- Cardiac Surgery Unit, Cardio-thoraco-vascular and Public Health Department, Padova University Hospital, Padua, Italy
| | - Thomas Beyerle
- Department of Cardiothoracic Surgery, University of Louisville, 201 Abraham Flexner Way, Suite 1200, Louisville, KY, 40202, USA
| | - Mark S Slaughter
- Department of Cardiothoracic Surgery, University of Louisville, 201 Abraham Flexner Way, Suite 1200, Louisville, KY, 40202, USA
| | - Gino Gerosa
- Cardiac Surgery Unit, Cardio-thoraco-vascular and Public Health Department, Padova University Hospital, Padua, Italy
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2
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Leon M. Revolutionizing Donor Heart Procurement: Innovations and Future Directions for Enhanced Transplantation Outcomes. J Cardiovasc Dev Dis 2024; 11:235. [PMID: 39195143 DOI: 10.3390/jcdd11080235] [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: 07/03/2024] [Revised: 07/19/2024] [Accepted: 07/25/2024] [Indexed: 08/29/2024] Open
Abstract
Heart failure persists as a critical public health challenge, with heart transplantation esteemed as the optimal treatment for patients with end-stage heart failure. However, the limited availability of donor hearts presents a major obstacle to meeting patient needs. In recent years, the most groundbreaking progress in heart transplantation has been in donor heart procurement, significantly expanding the donor pool and enhancing clinical outcomes. This review comprehensively examines these advancements, including the resurgence of heart donation after circulatory death and innovative recovery and evaluation technologies such as normothermic machine perfusion and thoraco-abdominal normothermic regional perfusion. Additionally, novel preservation methods, including controlled hypothermic preservation and hypothermic oxygenated perfusion, are evaluated. The review also explores the use of extended-criteria donors, post-cardiopulmonary resuscitation donors, and high-risk donors, all contributing to increased donor availability without compromising outcomes. Future directions, such as xenotransplantation, biomarkers, and artificial intelligence in donor heart evaluation and procurement, are discussed. These innovations promise to address current limitations and optimize donor heart utilization, ultimately enhancing transplantation success. By identifying recent advancements and proposing future research directions, this review aims to provide insights into advancing heart transplantation and improving patient outcomes.
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Affiliation(s)
- Marc Leon
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Falk CVRB, Stanford, CA 94305, USA
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3
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Ertugrul IA, Puspitarani RADA, Wijntjes B, Vervoorn MT, Ballan EM, van der Kaaij NP, van Goor H, Westenbrink BD, van der Plaats A, Nijhuis F, van Suylen V, Erasmus ME. Ex Situ Left Ventricular Pressure-Volume Loop Analyses for Donor Hearts: Proof of Concept in an Ovine Experimental Model. Transpl Int 2024; 37:12982. [PMID: 39055346 PMCID: PMC11269103 DOI: 10.3389/ti.2024.12982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/26/2024] [Indexed: 07/27/2024]
Abstract
Ex situ heart perfusion (ESHP) has emerged as an important strategy to preserve donation after brain death (DBD) and donation after circulatory death (DCD) donor hearts. Clinically, both DBD and DCD hearts are successfully preserved using ESHP. Viability assessment is currently based on biochemical values, while a reliable method for graft function assessment in a physiologic working mode is unavailable. As functional assessment during ESHP has demonstrated the highest predictive value of outcome post-transplantation, this is an important area for improvement. In this study, a novel method for ex situ assessment of left ventricular function with pressure-volume loop analyses is evaluated. Ovine hearts were functionally evaluated during normothermic ESHP with the novel pressure-volume loop system. This system provides an afterload and adjustable preload to the left ventricle. By increasing the preload and measuring end-systolic elastance, the system could successfully assess the left ventricular function. End-systolic elastance at 60 min and 120 min was 2.8 ± 1.8 mmHg/mL and 2.7 ± 0.7 mmHg/mL, respectively. In this study we show a novel method for functional graft assessment with ex situ pressure-loop analyses during ESHP. When further validated, this method for pressure-volume assessments, could be used for better graft selection in both DBD and DCD donor hearts.
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Affiliation(s)
- I. A. Ertugrul
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - R. A. D. A. Puspitarani
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | | | - M. T. Vervoorn
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - E. M. Ballan
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
- Department of Cardiology, Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
- Netherlands Heart Institute, Utrecht, Netherlands
| | - N. P. van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - H. van Goor
- Department of Medical Biology and Pathology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - B. D. Westenbrink
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | | | | | - V. van Suylen
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - M. E. Erasmus
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
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Kaffka genaamd Dengler SE, Mishra M, van Tuijl S, de Jager SCA, Sluijter JPG, Doevendans PA, van der Kaaij NP. Validation of the slaughterhouse porcine heart model for ex-situ heart perfusion studies. Perfusion 2024; 39:555-563. [PMID: 36638055 PMCID: PMC10943619 DOI: 10.1177/02676591231152718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION To validate slaughterhouse hearts for ex-situ heart perfusion studies, we compared cold oxygenated machine perfusion in less expensive porcine slaughterhouse hearts (N = 7) to porcine hearts that are harvested following the golden standard in laboratory animals (N = 6). METHODS All hearts received modified St Thomas 2 crystalloid cardioplegia prior to 4 hours of cold oxygenated machine perfusion. Hearts were perfused with homemade modified Steen heart solution with a perfusion pressure of 20-25 mmHg to achieve a coronary flow between 100-200 mL/min. Reperfusion and testing was performed for 4 hours on a normothermic, oxygenated diluted whole blood loaded heart model. Survival was defined by a cardiac output above 3 L with a mean aortic pressure above 60 mmHg. RESULTS Both groups showed 100% functional survival, with laboratory hearts displaying superior cardiac function. Both groups showed similar decline in function over time. CONCLUSION We conclude that the slaughterhouse heart can be used as an alternative to laboratory hearts and provides a cost-effective method for future ex-situ heart perfusion studies.
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Affiliation(s)
| | - Mudit Mishra
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | | | - Saskia CA de Jager
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Joost PG Sluijter
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
- Netherlands Heart Institute, Moreelsepark 1, The Netherlands
| | - Niels P van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Alemany VS, Nomoto R, Saeed MY, Celik A, Regan WL, Matte GS, Recco DP, Emani SM, Del Nido PJ, McCully JD. Mitochondrial transplantation preserves myocardial function and viability in pediatric and neonatal pig hearts donated after circulatory death. J Thorac Cardiovasc Surg 2024; 167:e6-e21. [PMID: 37211245 DOI: 10.1016/j.jtcvs.2023.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/06/2023] [Accepted: 05/03/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Mitochondrial transplantation has been shown to preserve myocardial function and viability in adult porcine hearts donated after circulatory death (DCD) . Herein, we investigate the efficacy of mitochondrial transplantation for the preservation of myocardial function and viability in neonatal and pediatric porcine DCD heart donation. METHODS Circulatory death was induced in neonatal and pediatric Yorkshire pigs by cessation of mechanical ventilation. Hearts underwent 20 or 36 minutes of warm ischemia time (WIT), 10 minutes of cold cardioplegic arrest, and then were harvested for ex situ heart perfusion (ESHP). Following 15 minutes of ESHP, hearts received either vehicle (VEH) or vehicle containing isolated autologous mitochondria (MITO). A sham nonischemic group (SHAM) did not undergo WIT, mimicking donation after brain death heart procurement. Hearts underwent 2 hours each of unloaded and loaded ESHP perfusion. RESULTS Following 4 hours of ESHP perfusion, left ventricle developed pressure, dP/dt max, and fractional shortening were significantly decreased (P < .001) in DCD hearts receiving VEH compared with SHAM hearts. In contrast, DCD hearts receiving MITO exhibited significantly preserved left ventricle developed pressure, dP/dt max, and fractional shortening (P < .001 each vs VEH, not significant vs SHAM). Infarct size was significantly decreased in DCD hearts receiving MITO as compared with VEH (P < .001). Pediatric DCD hearts subjected to extended WIT demonstrated significantly preserved fractional shortening and significantly decreased infarct size with MITO (P < .01 each vs VEH). CONCLUSIONS Mitochondrial transplantation in neonatal and pediatric pig DCD heart donation significantly enhances the preservation of myocardial function and viability and mitigates against damage secondary to extended WIT.
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Affiliation(s)
- Victor S Alemany
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Rio Nomoto
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Mossab Y Saeed
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Aybuke Celik
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - William L Regan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Dominic P Recco
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - James D McCully
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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6
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Pigot H, Soltesz K, Steen S. Ex Vivo Working Porcine Heart Model. Methods Mol Biol 2024; 2803:87-107. [PMID: 38676887 DOI: 10.1007/978-1-0716-3846-0_7] [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: 04/29/2024]
Abstract
Ex vivo working porcine heart models allow for the study of a heart's function and physiology outside the living organism. These models are particularly useful due to the anatomical and physiological similarities between porcine and human hearts, providing an experimental platform to investigate cardiac disease or assess donor heart viability for transplantation. This chapter presents an in-depth discussion of the model's components, including the perfusate, preload, and afterload. We explore the challenges of emulating cardiac afterload and present a historical perspective on afterload modeling, discussing various methodologies and their respective limitations. An actively controlled afterload device is introduced to enhance the model's ability to rapidly adjust pressure in the large arteries, thereby providing a more accurate and dynamic experimental model. Finally, we provide a comprehensive experimental protocol for the ex vivo working porcine heart model.
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Affiliation(s)
- Henry Pigot
- Department of Automatic Control, Lund University, Lund, Sweden.
| | | | - Stig Steen
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
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7
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Nielsen WH, Gustafsson F, Olsen PS, Hansen PB, Rossing K, Lilleør NB, Møller-Sørensen PH, Møller CH. Short-term outcomes after heart transplantation using donor hearts preserved with ex vivo perfusion. SCAND CARDIOVASC J 2023; 57:2267804. [PMID: 37822186 DOI: 10.1080/14017431.2023.2267804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/01/2023] [Indexed: 10/13/2023]
Abstract
The standard Conventional Cold Storage (CCS) during heart transplantation procurement is associated with time-dependent ischemic injury to the graft, which is a significant independent risk factor for post-transplant early morbidity and mortality - especially when cold ischemic time exceeds four hours. Since 2018, Rigshospitalet (Copenhagen, Denmark) has been utilising ex vivo perfusion (Organ Care System, OCS) in selected cases. The objective of this study was to compare the short-term clinical outcomes of patients transplanted with OCS compared to CCS. Methods: This retrospective single-centre study was based on consecutive patients undergoing a heart transplant between January 2018 and April 2021. Patients were selected for the OCS group when the cold ischemic time was expected to exceed four hours. The primary outcome measure was six-month event-free survival. Results: In total, 48 patients were included in the study; nine were transplanted with an OCS heart. The two groups had no significant differences in baseline characteristics. Six-month event-free survival was 77.8% [95% CI: 54.9-100%] in the OCS group and 79.5% [95% CI: 67.8-93.2%] in the CCS group (p = 0.91). While the OCS group had a median out-of-body time that was 183 min longer (p < 0.0001), the cold ischemic time was reduced by 51 min (p = 0.007). Conclusion: In a Scandinavian setting, our data confirms that utilising OCS in heart procurement allows for a longer out-of-body time and a reduced cold ischemic time without negatively affecting safety or early post-transplant outcomes.
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Affiliation(s)
- William Herrik Nielsen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Skov Olsen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Bo Hansen
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kasper Rossing
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Nikolaj Bang Lilleør
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Hasse Møller-Sørensen
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Holdflod Møller
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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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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Kounatidis D, Brozou V, Anagnostopoulos D, Pantos C, Lourbopoulos A, Mourouzis I. Donor Heart Preservation: Current Knowledge and the New Era of Machine Perfusion. Int J Mol Sci 2023; 24:16693. [PMID: 38069017 PMCID: PMC10706714 DOI: 10.3390/ijms242316693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023] Open
Abstract
Heart transplantation remains the conventional treatment in end-stage heart failure, with static cold storage (SCS) being the standard technique used for donor preservation. Nevertheless, prolonged cold ischemic storage is associated with the increased risk of early graft dysfunction attributed to residual ischemia, reperfusion, and rewarming damage. In addition, the demand for the use of marginal grafts requires the development of new methods for organ preservation and repair. In this review, we focus on current knowledge and novel methods of donor preservation in heart transplantation. Hypothermic or normothermic machine perfusion may be a promising novel method of donor preservation based on the administration of cardioprotective agents. Machine perfusion seems to be comparable to cold cardioplegia regarding donor preservation and allows potential repair treatments to be employed and the assessment of graft function before implantation. It is also a promising platform for using marginal organs and increasing donor pool. New pharmacological cardiac repair treatments, as well as cardioprotective interventions have emerged and could allow for the optimization of this modality, making it more practical and cost-effective for the real world of transplantation. Recently, the use of triiodothyronine during normothermic perfusion has shown a favorable profile on cardiac function and microvascular dysfunction, likely by suppressing pro-apoptotic signaling and increasing the expression of cardioprotective molecules.
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Affiliation(s)
| | | | | | | | | | - Iordanis Mourouzis
- Department of Pharmacology, National and Kapodistrian University of Athens, 11527 Athens, Greece; (D.K.); (V.B.); (D.A.); (C.P.); (A.L.)
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10
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Spencer BL, Wilhelm SK, Urrea KA, Chakrabortty V, Sewera SJ, Mazur DE, Bartlett RH, Rojas-Peña A, Drake DH. Twenty-Four Hour Normothermic Ex Vivo Heart Perfusion With Hemofiltration In an Adult Porcine Model. Transplant Proc 2023; 55:2241-2246. [PMID: 37783593 DOI: 10.1016/j.transproceed.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/28/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Historically, cardiac transplantation relied on cold static storage at 5 °C for ex vivo myocardial preservation. Currently, machine perfusion is the standard of care at many transplant centers. These storage methods are limited to 12 hours. We sought to evaluate the efficacy of hemofiltration and filtrate replacement in adult porcine hearts using normothermic heart perfusion (NEVHP) for 24 hours. METHODS We performed 24-hour NEVHP on 5 consecutive hearts. After anesthetic induction, sternotomy, cardioplegia administration, explantation, and back-table instrumentation, NEVHP was initiated in beating, unloaded mode. After 1 hour, plasma exchange was performed, and hemofiltration was initiated. Heart function parameters and arterial blood gasses were obtained hourly. RESULTS All hearts (n = 5) were viable at the 24-hour mark. The average left ventricular systolic pressure at the beginning of the prep was 36.6 ± 7.9 mm Hg compared with 27 ± 5.5 mm Hg at the end. Coronary resistance at the beginning of prep was 0.79 ± 0.10 mm Hg/L/min and 0.93 ± 0.28 mm Hg/L/min at the end. Glucose levels averaged 223 ± 13.9 mg/dL, and the lactate average at the termination of prep was 2.6 ± 0.3 mmol/L. CONCLUSIONS We successfully perfused adult porcine hearts at normothermic temperatures for 24 hours with results comparable to our pediatric porcine heart model. The next step in our research is NEVHP evaluation in a working mode using left atrial perfusion.
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Affiliation(s)
- Brianna L Spencer
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Spencer K Wilhelm
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Kristopher A Urrea
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Vikramjit Chakrabortty
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Sebastian J Sewera
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | | | - Robert H Bartlett
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Alvaro Rojas-Peña
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI; Department of Surgery, Section of Transplantation, University of Michigan, Ann Arbor, MI
| | - Daniel H Drake
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI; Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI.
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11
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Jen N, Hadfield J, Bessa GM, Amabili M, Nobes DS, Chung HJ. Jacketed elastomeric tubes for passive self-regulation of pulsatile flow. J Mech Behav Biomed Mater 2023; 145:105994. [PMID: 37418970 DOI: 10.1016/j.jmbbm.2023.105994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/22/2023] [Accepted: 06/24/2023] [Indexed: 07/09/2023]
Abstract
Regulating pulsatile flow is important to achieve optimal separation and mixing and enhanced heat transfer in microfluidic devices, as well as maintaining homeostasis in biological systems. The human aorta, a composite and layered tube made (among others) of elastin and collagen, is an inspiration for researchers who seek an engineering solution for a self-regulation of pulsatile flow. Here, we present a bio-inspired approach showing that fabric-jacketed elastomeric tubes, manufactured using commercially available silicone rubber and knitted textiles, can be used to regulate pulsatile flow. Our tubes are evaluated via incorporation into a mock-circulatory 'flow loop' that replicates the pulsatile fluid flow conditions of an ex-vivo heart perfusion (EVHP) device, a machine used in heart transplants. Pressure waveforms measured near the elastomeric tubing clearly indicated an effective flow regulation. The 'dynamic stiffening' behavior of the tubes during deformation is analyzed quantitatively. Broadly, the fabric jackets allow for the tubes to experience greater magnitudes of pressure and distension without risk of asymmetric aneurysm within the expected operating time of an EVHP. Owing to its highly tunable nature, our design may serve as a basis for tubing systems that require passive self-regulation of pulsatile flow.
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Affiliation(s)
- Nathan Jen
- Department of Chemical and Materials Engineering, University of Alberta, Edmonton, AB, Canada
| | - Jake Hadfield
- Department of Mechanical Engineering, University of Alberta, Edmonton, AB, Canada
| | - Guilherme M Bessa
- Department of Mechanical Engineering, University of Alberta, Edmonton, AB, Canada
| | - Marco Amabili
- Department of Mechanical Engineering, McGill University, Montreal, QC, Canada
| | - David S Nobes
- Department of Mechanical Engineering, University of Alberta, Edmonton, AB, Canada.
| | - Hyun-Joong Chung
- Department of Chemical and Materials Engineering, University of Alberta, Edmonton, AB, Canada.
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12
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Kaffka Genaamd Dengler SE, Mishra M, van Tuijl S, de Jager SCA, Sluijter JPG, Doevendans PA, van der Kaaij NP. Cold Oxygenated Machine Perfusion Improves Functional Survival of Slaughterhouse Porcine Hearts. ASAIO J 2023; 69:774-781. [PMID: 37146423 DOI: 10.1097/mat.0000000000001955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
The aim of our study was to explore the effect of cold oxygenated machine perfusion in slaughterhouse porcine hearts on functional myocardial survival compared to static cold storage (SCS). Seventeen hearts were harvested from Dutch Landrace Hybrid pigs, which were sacrificed for human consumption and randomly assigned to the 4 hours SCS group (N = 10) or the 4 hours cold oxygenated machine perfusion group (N = 7). Hearts were perfused with a homemade Heart Solution with a perfusion pressure of 20-25 mm Hg to achieve a coronary flow between 100 and 200 ml/minute. After 4 hours of preservation, all hearts were functionally assessed during 4 hours on a normothermic, oxygenated diluted whole blood (1:2) loaded heart model. Survival was defined by a cardiac output above 3 L with a mean aortic pressure above 60 mm Hg. Survival was significantly better in the cold oxygenated machine perfusion group, where 100% of the hearts reached the 4 hours end-point, as compared with 30% in the SCS group ( p = 0.006). Interestingly, warm ischemic time was inversely related to survival in the SCS group with a correlation coefficient of -0.754 ( p = 0.012). Cold oxygenated machine perfusion improves survival of the slaughterhouse porcine heart.
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Affiliation(s)
| | - Mudit Mishra
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Laboratory of Experimental Cardiology, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | | | - Saskia C A de Jager
- Laboratory of Experimental Cardiology, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Joost P G Sluijter
- Laboratory of Experimental Cardiology, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - Niels P van der Kaaij
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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13
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Coliță CI, Olaru DG, Coliță D, Hermann DM, Coliță E, Glavan D, Popa-Wagner A. Induced Coma, Death, and Organ Transplantation: A Physiologic, Genetic, and Theological Perspective. Int J Mol Sci 2023; 24:ijms24065744. [PMID: 36982814 PMCID: PMC10059721 DOI: 10.3390/ijms24065744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
In the clinic, the death certificate is issued if brain electrical activity is no longer detectable. However, recent research has shown that in model organisms and humans, gene activity continues for at least 96 h postmortem. The discovery that many genes are still working up to 48 h after death questions our definition of death and has implications for organ transplants and forensics. If genes can be active up to 48 h after death, is the person technically still alive at that point? We discovered a very interesting parallel between genes that were upregulated in the brain after death and genes upregulated in the brains that were subjected to medically-induced coma, including transcripts involved in neurotransmission, proteasomal degradation, apoptosis, inflammation, and most interestingly, cancer. Since these genes are involved in cellular proliferation, their activation after death could represent the cellular reaction to escape mortality and raises the question of organ viability and genetics used for transplantation after death. One factor limiting the organ availability for transplantation is religious belief. However, more recently, organ donation for the benefit of humans in need has been seen as “posthumous giving of organs and tissues can be a manifestation of love spreading also to the other side of death”.
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Affiliation(s)
- Cezar-Ivan Coliță
- Doctoral School, University of Medicine and Pharmacy Carol Davila, 020276 Bucharest, Romania; (C.-I.C.)
| | - Denissa-Greta Olaru
- Department of Psychiatry, University for Medicine and Pharmacy Craiova, 200349 Craiova, Romania;
| | - Daniela Coliță
- Doctoral School, University of Medicine and Pharmacy Carol Davila, 020276 Bucharest, Romania; (C.-I.C.)
| | - Dirk M. Hermann
- Chair of Vascular Neurology, Dementia and Ageing, Department of Neurology, University Hospital Essen, 45147 Essen, Germany
| | - Eugen Coliță
- Doctoral School, University of Medicine and Pharmacy Carol Davila, 020276 Bucharest, Romania; (C.-I.C.)
| | - Daniela Glavan
- Department of Psychiatry, University for Medicine and Pharmacy Craiova, 200349 Craiova, Romania;
- Correspondence: (D.G.); (A.P.-W.)
| | - Aurel Popa-Wagner
- Department of Psychiatry, University for Medicine and Pharmacy Craiova, 200349 Craiova, Romania;
- Chair of Vascular Neurology, Dementia and Ageing, Department of Neurology, University Hospital Essen, 45147 Essen, Germany
- Correspondence: (D.G.); (A.P.-W.)
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14
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Sakota D, Kosaka R, Nagaoka E, Ohuchi K, Tahara T, Arai H, Sakanoue I, McCurry KR, Okamoto T. Left ventricular assist device mode: Co-pulse left ventricular unloading in a working mode of ex vivo heart perfusion. J Heart Lung Transplant 2023; 42:707-715. [PMID: 36931988 DOI: 10.1016/j.healun.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 11/10/2022] [Accepted: 01/14/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND For normothermic ex vivo heart perfusion (EVHP), a resting mode and working mode have been proposed. We newly developed a left ventricular assist device (LVAD) mode that supports heart contraction by co-pulse synchronized LVAD. METHODS Following resting mode during time 0 to 1 hour, pig hearts (n = 18) were perfused in either resting, working, or LVAD mode during time 1 to 5 hour, and then myocardial function was evaluated in working mode at 6 hour. The preservation ratio was defined as the myocardial mechanical function at 330 minute divided by the function at 75 minute. In LVAD mode, LVAD unloaded the pressure and the volume in the left ventricle in the systolic phase. RESULTS The LVAD group was significantly associated with higher preservation ratios in cardiac output (resting, 33 ± 3; working, 35 ± 5; LVAD, 76% ± 5%; p < 0.001), stroke work, dP/dt maximum, and dP/dt minimum compared with the other groups. Glucose consumption was significantly reduced in the resting group. The LVAD group was significantly associated with higher myocardial oxygen consumption (resting, 2.2 ± 0.3; working; 4.6 ± 0.5; LVAD, 6.1 ± 0.5 mL O2/min/100 g, p < 0.001) and higher adenosine triphosphate (ATP) levels (resting, 1.1 ± 0.1; working, 0.7 ± 0.1; LVAD, 1.6 ± 0.2 μmol/g, p = 0.001) compared with the others. CONCLUSION These data suggest that myocardial mechanical function was better preserved in LVAD mode than in resting and working modes. Although our data suggested similar glycolysis activity in the LVAD and working groups, the higher final ATP in the LVAD group might be explained by reduced external work in LVAD.
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Affiliation(s)
- Daisuke Sakota
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan.
| | - Ryo Kosaka
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan
| | - Eiki Nagaoka
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Katsuhiro Ohuchi
- Department of Advanced Surgical Technology Research and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomoki Tahara
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ichiro Sakanoue
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Transplant Center, Cleveland Clinic, Cleveland, Ohio
| | - Kenneth R McCurry
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Transplant Center, Cleveland Clinic, Cleveland, Ohio
| | - Toshihiro Okamoto
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Transplant Center, Cleveland Clinic, Cleveland, Ohio.
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15
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Hatami S, Conway J, Freed DH, Urschel S. Thoracic organ donation after circulatory determination of death. TRANSPLANTATION REPORTS 2023. [DOI: 10.1016/j.tpr.2022.100125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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16
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Li JH, Xu X, Wang YF, Xie HY, Chen JY, Dong NG, Badiwala M, Xin LM, Ribeiro RVP, Yin H, Zhang H, Zhang JZ, Huo F, Yang JY, Yang HJ, Pan H, Li SG, Qiao YB, Luo J, Li HY, Jia JJ, Yu H, Liang H, Yang SJ, Wang H, Liu ZY, Zhang LC, Hu XY, Wu H, Hu YQ, Tang PF, Ye QF, Zheng SS. Chinese expert consensus on organ protection of transplantation (2022 edition). Hepatobiliary Pancreat Dis Int 2022; 21:516-526. [PMID: 36376226 DOI: 10.1016/j.hbpd.2022.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/24/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Jian-Hui Li
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China
| | - Xiao Xu
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China
| | - Yan-Feng Wang
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430062, China
| | - Hai-Yang Xie
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Jing-Yu Chen
- Wuxi Lung Transplantation Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi 214023, China
| | - Nian-Guo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Mitesh Badiwala
- Peter Munk Cardiac Centre, Toronto General Hospital-University Health Network, Toronto, Canada
| | - Li-Ming Xin
- School of Computer Engineering and Science, Shanghai University, Shanghai 200444, China
| | | | - Hao Yin
- Organ Transplant Center, Shanghai Changzheng Hospital, Shanghai 200003, China
| | - Hao Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Jian-Zheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Feng Huo
- Department of Surgery, General Hospital of Guangzhou Military Command of PLA, Guangzhou 510040, China
| | - Jia-Yin Yang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Hong-Ji Yang
- Organ Transplantation Center, Sichuan Provincial People's Hospital and School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Hui Pan
- Department of Lung Transplantation, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Shao-Guang Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Yin-Biao Qiao
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Jia Luo
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Hao-Yu Li
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Jun-Jun Jia
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hao Yu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Han Liang
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430062, China
| | - Si-Jia Yang
- Department of Lung Transplantation, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hao Wang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Zhong-Yang Liu
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Li-Cheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Xiao-Yi Hu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hao Wu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Yi-Qing Hu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Pei-Fu Tang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Qi-Fa Ye
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430062, China
| | - Shu-Sen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China; NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China; Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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17
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Vasanthan V, Rieger J, Holloway DD, Clarke B, Miller R, Kent WD. Sternum-Sparing Left Ventricular Assist Device Insertion Reduces Perioperative Transfusions and Blood Loss: A Single-Centre Canadian Experience. CJC Open 2022; 4:833-839. [PMID: 36254329 PMCID: PMC9568692 DOI: 10.1016/j.cjco.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Left ventricular assist devices (LVADs) improve survival and quality of life, as either destination therapy or a bridge to transplantation. Although less-invasive hemisternotomy approaches for LVAD implantation are well studied, only a paucity of data is available in the literature on sternum-sparing bilateral minithoracotomy (BMT). Our centre has one of Canada’s most extensive experiences with the BMT approach. Herein, we compared LVAD implantation via BMT with patients who received full median sternotomy or hemisternotomy. Methods A single-centre retrospective review of data from Foothills Medical Centre (Calgary, Canada) was performed. Patients underwent LVAD insertion from 2012 to 2019, receiving either BMT (n = 11) or sternotomy (full median sternotomy or upper hemisternotomy with left minithoracotomy; n = 38). Intraoperative and early postoperative outcomes were assessed. Results Patients who received BMT had significantly fewer transfusions of red blood cells, fresh frozen plasma, and platelets. The BMT group had lower chest-tube output in the first 12 hours. No significant differences occurred in ventilation time, intensive care unit length of stay, mortality, stroke, or reoperation for bleeding. Conclusions Outcomes suggest that sternum-sparing LVAD implantation is a feasible alternative to sternotomy, leading to less postoperative blood loss and transfusion in the early postoperative period. Less transfusion is particularly valuable in this patient population, to reduce antigen-related sensitization prior to transplantation. Additional study is needed to assess potential benefits related to right heart function, postoperative mobility, and re-entry for transplantation.
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18
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Pigot H, Soltesz K, Paskevicius A, Liao Q, Sjöberg T, Steen S. A novel nonlinear afterload for ex vivo heart evaluation: porcine experimental results. Artif Organs 2022; 46:1794-1803. [PMID: 35548921 PMCID: PMC9545718 DOI: 10.1111/aor.14307] [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: 01/04/2022] [Revised: 04/13/2022] [Accepted: 04/29/2022] [Indexed: 11/28/2022]
Abstract
Background Existing working heart models for ex vivo functional evaluation of donor hearts often use cardiac afterloads made up of discrete resistive and compliant elements. This approach limits the practicality of independently controlling systolic and diastolic aortic pressure to safely test the heart under multiple loading conditions. We present and investigate a novel afterload concept designed to enable such control. Methods Six ∼70 kg pig hearts were evaluated in vivo, then ex vivo in left‐ventricular working mode using the presented afterload. Both in vivo and ex vivo, the hearts were evaluated at two exertion levels: at rest and following a 20 μg adrenaline bolus, while measuring aortic pressure and flow, left ventricular pressure and volume, and left atrial pressure. Results The afterload gave aortic pressure waveforms that matched the general shape of the in vivo measurements. A wide range of physiological systolic pressures (93 to 160 mm Hg) and diastolic pressures (73 to 113 mm Hg) were generated by the afterload. Conclusions With the presented afterload concept, multiple physiological loading conditions could be tested ex vivo, and compared with the corresponding in vivo data. An additional control loop from the set pressure limits to the measured systolic and diastolic aortic pressure is proposed to address discrepancies observed between the set limits and the measured pressures.
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Affiliation(s)
- Henry Pigot
- Lund University, Dept Automatic Control, Sweden
| | | | - Audrius Paskevicius
- Lund University, Div. Thoracic Surgery, Dept. Clinical Sciences and Skane° University Hospital, Dept. Cardiothoracic Surgery, Sweden
| | - Qiuming Liao
- Lund University, Div. Thoracic Surgery, Dept. Clinical Sciences and Skane° University Hospital, Dept. Cardiothoracic Surgery, Sweden
| | - Trygve Sjöberg
- Lund University, Div. Thoracic Surgery, Dept. Clinical Sciences and Skane° University Hospital, Dept. Cardiothoracic Surgery, Sweden
| | - Stig Steen
- Lund University, Div. Thoracic Surgery, Dept. Clinical Sciences and Skane° University Hospital, Dept. Cardiothoracic Surgery, Sweden
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19
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Truby LK, Casalinova S, Patel CB, Agarwal R, Holley CL, Mentz RJ, Milano C, Bryner B, Schroder JN, Devore AD. Donation After Circulatory Death in Heart Transplantation: History, Outcomes, Clinical Challenges, and Opportunities to Expand the Donor Pool. J Card Fail 2022; 28:1456-1463. [PMID: 35447338 DOI: 10.1016/j.cardfail.2022.03.353] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/15/2022]
Abstract
Heart transplantation remains the gold-standard therapy for end-stage heart failure; the expected median survival range is 12-13 years. More than 30,000 heart transplants have been performed globally in the past decade alone. With advances in medical and surgical therapies for heart failure, including durable left ventricular assist devices, an increasing number of patients are living with end-stage disease. Last year alone, more than 2500 patients were added to the heart-transplant waitlist in the United States. Despite recent efforts to expand the donor pool, including an increase in transplantation of hepatitis C-positive and extended-criteria donors, supply continues to fall short of demand. Donation after circulatory death (DCD), defined by irreversible cardiopulmonary arrest rather than donor brain death, is widely used in other solid-organ transplants, including kidney and liver, but has not been widely adopted in heart transplantation. However, resurging interest in DCD donation and the introduction of ex vivo perfusion technology has catalyzed recent clinical trials and the development of DCD heart-transplantation programs. Herein, we review the history of DCD heart transplantation, describe the currently used procurement protocols for it and examine clinical challenges and outcomes of such a procedure.
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Affiliation(s)
- Lauren K Truby
- From the Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Sarah Casalinova
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Richa Agarwal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Christopher L Holley
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Carmelo Milano
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Benjamin Bryner
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Adam D Devore
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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20
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Hatami S, Hefler J, Freed DH. Inflammation and Oxidative Stress in the Context of Extracorporeal Cardiac and Pulmonary Support. Front Immunol 2022; 13:831930. [PMID: 35309362 PMCID: PMC8931031 DOI: 10.3389/fimmu.2022.831930] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal circulation (ECC) systems, including cardiopulmonary bypass, and extracorporeal membrane oxygenation have been an irreplaceable part of the cardiothoracic surgeries, and treatment of critically ill patients with respiratory and/or cardiac failure for more than half a century. During the recent decades, the concept of extracorporeal circulation has been extended to isolated machine perfusion of the donor organ including thoracic organs (ex-situ organ perfusion, ESOP) as a method for dynamic, semi-physiologic preservation, and potential improvement of the donor organs. The extracorporeal life support systems (ECLS) have been lifesaving and facilitating complex cardiothoracic surgeries, and the ESOP technology has the potential to increase the number of the transplantable donor organs, and to improve the outcomes of transplantation. However, these artificial circulation systems in general have been associated with activation of the inflammatory and oxidative stress responses in patients and/or in the exposed tissues and organs. The activation of these responses can negatively affect patient outcomes in ECLS, and may as well jeopardize the reliability of the organ viability assessment, and the outcomes of thoracic organ preservation and transplantation in ESOP. Both ECLS and ESOP consist of artificial circuit materials and components, which play a key role in the induction of these responses. However, while ECLS can lead to systemic inflammatory and oxidative stress responses negatively affecting various organs/systems of the body, in ESOP, the absence of the organs that play an important role in oxidant scavenging/antioxidative replenishment of the body, such as liver, may make the perfused organ more susceptible to inflammation and oxidative stress during extracorporeal circulation. In the present manuscript, we will review the activation of the inflammatory and oxidative stress responses during ECLP and ESOP, mechanisms involved, clinical implications, and the interventions for attenuating these responses in ECC.
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Affiliation(s)
- Sanaz Hatami
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
| | - Joshua Hefler
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H. Freed
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Department of Physiology, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Darren H. Freed,
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21
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Lactate during ex-situ heart perfusion does not predict the requirement for mechanical circulatory support following donation after circulatory death (DCD) heart transplants. J Heart Lung Transplant 2022; 41:1294-1302. [DOI: 10.1016/j.healun.2022.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 01/16/2022] [Accepted: 02/01/2022] [Indexed: 11/22/2022] Open
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22
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Hondjeu ARM, Mashari A, Ramos R, Ruggeri GM, Gellner B, Ribeiro RVP, Hiansen JQ, Yu F, Xin L, Adamson MB, Badiwala MV, Meineri M. Echocardiographic assessment of left ventricular function in ex situ heart perfusion using pump-supported and passive afterload working mode: a pilot study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2021; 1:20. [PMID: 37386658 DOI: 10.1186/s44158-021-00018-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/29/2021] [Indexed: 07/01/2023]
Abstract
Ex situ heart perfusion (ESHP) has been developed to decrease cold ischemia time and allow metabolic assessment of donor hearts prior to transplantation. Current clinical ESHP systems preserve the heart in an unloaded condition and only evaluate the cardiac metabolic profile. In this pilot study we performed echocardiographic functional assessment using two alternative systems for left ventricular (LV) loading: pump supported afterload working mode (SAM) and passive afterload working modes (PAM). Six hearts were procured from male Yorkshire pigs. During cold ischemia, hearts were mounted on our custom made ESHP circuit and a 3D-printed enclosure for the performance of echocardiography with a standard TEE probe. Following perfusion with Langherdorf mode of the unloaded heart, the system was switched into different working modes to allow LV loading and functional assessment: pump supported (SAM) and passive (PAM). Echocardiographic assessment of left ventricular function in the donor hearts was performed in vivo and at 1 h of ESHP with SAM, after 4.5 h with PAM and after 5.5 h with SAM. We obtained good quality epicardial echocardiographic images at all time points allowing a comprehensive LV systolic assessment. All indices showed a decrease in LV systolic function throughout the trial with the biggest drop after heart harvesting. We demonstrated the feasibility of echocardiographic functional assessment during ESHP and two different working modes. The expected LV systolic dysfunction consisted of a reduction in EF, FAC, FS, and strain throughout the experiment with the most significant decrease after harvesting.
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Affiliation(s)
- Arnaud Romeo Mbadjeu Hondjeu
- Department of Anesthesia and Pain Management, Peter Munk Cardiac Center Toronto General Hospital, University Health Network, Toronto, Canada
| | - Azad Mashari
- Department of Anesthesia and Pain Management, Peter Munk Cardiac Center Toronto General Hospital, University Health Network, Toronto, Canada
| | - Ryan Ramos
- Department of Anesthesia and Pain Management, Peter Munk Cardiac Center Toronto General Hospital, University Health Network, Toronto, Canada
| | - Giulia Maria Ruggeri
- Department of Anesthesia and Pain Management, Peter Munk Cardiac Center Toronto General Hospital, University Health Network, Toronto, Canada
| | - Bryan Gellner
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada
| | - Roberto Vanin Pinto Ribeiro
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Joshua Qua Hiansen
- Department of Anesthesia and Pain Management, Peter Munk Cardiac Center Toronto General Hospital, University Health Network, Toronto, Canada
| | - Frank Yu
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Liming Xin
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Mitchell Brady Adamson
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Mitesh Vallabh Badiwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Massimiliano Meineri
- Department of Anesthesia and Pain Management, Peter Munk Cardiac Center Toronto General Hospital, University Health Network, Toronto, Canada.
- Department of Anesthesia and Intensive Care, Herzzentrum Leipzig, Strumpell Strasse 39, 04289, Leipzig, Germany.
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Hatami S, Qi X, White CW, Bozso SJ, Himmat S, Sergi C, Nagendran J, Chung HJ, Nobes DS, Freed DH. The Position of the Heart During Normothermic Ex Situ Heart Perfusion is an Important Factor in Preservation and Recovery of Myocardial Function. ASAIO J 2021; 67:1222-1231. [PMID: 33741785 DOI: 10.1097/mat.0000000000001386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Ex situ heart perfusion (ESHP) is being investigated as a method for the continuous preservation of the myocardium in a semiphysiologic state for subsequent transplantation. Most methods of ESHP position the isolated heart in a hanging (H) state, representing a considerable departure from the in vivo anatomical positioning of the heart and may negatively affect the functional preservation of the heart. In the current study, cardiac functional and metabolic parameters were assessed in healthy pig hearts, perfused for 12 hours, in either an H, or supported (S) position, either in nonworking mode (NWM) or working mode (WM). The cardiac function was best preserved in the S position hearts in WM (median 11 hour cardiac index (CI)/1 hour CI%: working mode perfusion in supported position = 94.77% versus nonworking mode perfusion in supported position = 62.80%, working mode perfusion in H position = 36.18%, nonworking mode perfusion in H position = 9.75%; p < 0.001). Delivery of pyruvate bolus significantly improved the function in S groups, however, only partially reversed myocardial dysfunction in the H heart groups. The hearts perfused ex situ in a semianatomical S position and in physiologic WM had better functional preservation and recovery than the H hearts in non-S position. Optimizing the positional support for the ex situ-perfused hearts may improve myocardial preservation during ESHP.
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Affiliation(s)
- Sanaz Hatami
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
| | - Xiao Qi
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
| | - Christopher W White
- Department of surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sabin J Bozso
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
| | - Sayed Himmat
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
| | - Consolato Sergi
- Department of Laboratory Medicine and Pathology, Faculty of Medicine, Canada
| | - Jayan Nagendran
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
- Canadian Donation and Transplantation Research Program, Canada
| | - Hyun-Joong Chung
- Department of Chemical and Materials Engineering Faculty of Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - David S Nobes
- Department of Mechanical Engineering, Faculty of Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Darren H Freed
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
- Canadian Donation and Transplantation Research Program, Canada
- Department of Physiology, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Department of Biomedical Engineering, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
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24
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van Suylen V, Vandendriessche K, Neyrinck A, Nijhuis F, van der Plaats A, Verbeken EK, Vermeersch P, Meyns B, Mariani MA, Rega F, Erasmus ME. Oxygenated machine perfusion at room temperature as an alternative for static cold storage in porcine donor hearts. Artif Organs 2021; 46:246-258. [PMID: 34633676 PMCID: PMC9298357 DOI: 10.1111/aor.14085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/15/2021] [Accepted: 10/05/2021] [Indexed: 01/06/2023]
Abstract
Background There is a continued interest in ex situ heart perfusion as an alternative strategy for donor heart preservation. We hypothesize that oxygenated machine perfusion of donor hearts at a temperature that avoids both normothermia and deep hypothermia offers adequate and safe preservation. Methods Cardioplegia‐arrested porcine donor hearts were randomly assigned to six hours of preservation using cold storage (CS, n = 5) or machine perfusion using an oxygenated acellular perfusate at 21°C (MP, n = 5). Subsequently, all grafts were evaluated using the Langendorff method for 120 min. Metabolic parameters and histology were analyzed. Systolic function was assessed by contractility and elastance. Diastolic function was assessed by lusitropy and stiffness. Results For both groups, in vivo baseline and post‐Langendorff biopsies were comparable, as were lactate difference and myocardial oxygen consumption. Injury markers gradually increased and were comparable. Significant weight gain was seen in MP (p = 0.008). Diastolic function was not impaired in MP, and lusitropy was superior from 30 min up to 90 min of reperfusion. Contractility was superior in MP during the first hour of evaluation. Conclusion We conclude that the initial functional outcome of MP‐preserved hearts was transiently superior compared to CS, with no histological injury post‐Langendorff. Our machine perfusion strategy could offer feasible and safe storage of hearts prior to transplantation. Future studies are warranted for further optimization.
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Affiliation(s)
- Vincent van Suylen
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Arne Neyrinck
- Laboratory of Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, Catholic University Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Erik K Verbeken
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Histopathology, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Vermeersch
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Filip Rega
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Michiel E Erasmus
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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25
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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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26
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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: 18] [Impact Index Per Article: 6.0] [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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27
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A Multi-Mode System for Myocardial Functional and Physiological Assessment during Ex Situ Heart Perfusion. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:303-313. [PMID: 33343033 DOI: 10.1182/ject-2000034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022]
Abstract
Ex situ heart perfusion (ESHP) has proven to be an important and valuable step toward better preservation of donor hearts for heart transplantation. Currently, few ESHP systems allow for a convenient functional and physiological evaluation of the heart. We sought to establish a simple system that provides functional and physiological assessment of the heart during ESHP. The ESHP circuit consists of an oxygenator, a heart-lung machine, a heater-cooler unit, an anesthesia gas blender, and a collection funnel. Female Yorkshire pig hearts (n = 10) had del Nido cardioplegia (4°C) administered, excised, and attached to the perfusion system. Hearts were perfused retrogradely into the aortic root for 2 hours before converting the system to an isovolumic mode or a working mode for further 2 hours. Blood samples were analyzed to measure metabolic parameters. During the isovolumic mode (n = 5), a balloon inserted in the left ventricular (LV) cavity was inflated so that an end-diastolic pressure of 6-8 mmHg was reached. During the working mode (n = 5), perfusion in the aortic root was redirected into left atrium (LA) using a compliance chamber which maintained an LA pressure of 6-8 mmHg. Another compliance chamber was used to provide an afterload of 40-50 mmHg. Hemodynamic and metabolic conditions remained stable and consistent for a period of 4 hours of ESHP in both isovolumic mode (LV developed pressure: 101.0 ± 3.5 vs. 99.7 ± 6.8 mmHg, p = .979, at 2 and 4 hours, respectively) and working mode (LV developed pressure: 91.0 ± 2.6 vs. 90.7 ± 2.5 mmHg, p = .942, at 2 and 4 hours, respectively). The present study proposed a novel ESHP system that enables comprehensive functional and metabolic assessment of large mammalian hearts. This system allowed for stable myocardial function for up to 4 hours of perfusion, which would offer great potential for the development of translational therapeutic protocols to improve dysfunctional donated hearts.
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28
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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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29
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Kadowaki S, Kotani Y, Kobayashi Y, Goto T, Kasahara S. Assessment of the right ventricle in donation after circulatory death hearts. Artif Organs 2020; 45:263-270. [PMID: 32979873 DOI: 10.1111/aor.13823] [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: 08/03/2020] [Revised: 09/13/2020] [Accepted: 09/13/2020] [Indexed: 11/30/2022]
Abstract
In donation after circulatory death heart transplantation, the donor heart is exposed to circulatory load. The right ventricle, due to its structure, has high compliance for volume load but is particularly vulnerable to increased pressure load. This study used a porcine model to conduct a functional assessment of the hemodynamics of the heart, with a focus on the right ventricle. Six pigs weighing 24.6 ± 1.4 kg were used. Circulatory death was induced by asphyxiation after median sternotomy. After 30 minutes in the state of global warm ischemia, the ascending aorta was clamped, followed by a 20-minute reperfusion of the heart with a 20°C blood cardioplegia solution. Systemic circulation was established by cardiopulmonary bypass after aortic cross-clamping. After initial reperfusion, the blood cardioplegia solution was replaced with blood. The blood was then rewarmed while the heart was still in a non-working state. Cardiac function was assessed twice in situ, first by the thermodilution method, and then, by the pressure-volume measurement both at preischemia and at three hours after initiation of reperfusion. The recovery rate of cardiac output was 75%. End-systolic elastance (P = .02) and pulmonary arterial elastance significantly increased (P = .03), but the ratio of arterial elastance to end-systolic elastance was preserved (P = .91) in the right ventricle. Despite a decrease in cardiac output after reperfusion from warm ischemia, the right ventricle had a potential to respond the elevated afterload. It is important that donations after circulatory death heart transplantation should be performed with attention to avoiding right ventricular distension.
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Affiliation(s)
- Sachiko Kadowaki
- Department of Cardiovascular Surgery, Okayama University, Okayama, Japan
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, Okayama University, Okayama, Japan
| | - Yasuyuki Kobayashi
- Department of Cardiovascular Surgery, Okayama University, Okayama, Japan
| | - Takuya Goto
- Department of Cardiovascular Surgery, Okayama University, Okayama, Japan
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University, Okayama, Japan
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30
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Cameron K, El Hassan M, Sabbagh R, Freed DH, Nobes DS. Experimental investigation into the effect of compliance of a mock aorta on cardiac performance. PLoS One 2020; 15:e0239604. [PMID: 33044976 PMCID: PMC7549783 DOI: 10.1371/journal.pone.0239604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 09/10/2020] [Indexed: 11/23/2022] Open
Abstract
Demand for heart transplants far exceeds supply of donated organs. This is attributed to the high percentage of donor hearts that are discarded and to the narrow six-hour time window currently available for transplantation. Ex-vivo heart perfusion (EVHP) provides the opportunity for resuscitation of damaged organs and extended transplantation time window by enabling functional assessment of the hearts in a near-physiologic state. Present work investigates the fluid mechanics of the ex-vivo flow loop and corresponding impact on cardiac performance. A mechanical flow loop is developed that is analogous to the region of the EVHP system that mimics in-vivo systemic circulation, including the body’s largest and most compliant artery, the aorta. This investigation is focused on determining the effect of mock aortic tubing compliance on pump performance. A custom-made silicone mock aorta was developed to simulate a range of in-vivo conditions and a physiological flow was generated using a commercial ventricular assist device (VAD). Monitored parameters, including pressure, tube distension and downstream velocity, acquired using time-resolved particle imaging velocimetry (PIV), were applied to an unsteady Bernoulli analysis of the flow in a novel way to evaluate pump performance as a proxy for cardiac workload. When compared to the rigid case, the compliant mock aorta case demonstrated healthier physiologic pressure waveforms, steadier downstream flow and reduced energetic demands on the pump. These results provide experimental verification of Windkessel theory and support the need for a compliant mock aorta in the EVHP system.
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Affiliation(s)
- Katie Cameron
- Department of Biomedical Engineering, University of Alberta, Edmonton, Canada
| | - Mouhammad El Hassan
- Prince Mohammad Bin Fahd University, Al-Khobar, Saudi Arabia
- Department of Mechanical Engineering, University of Alberta, Edmonton, Canada
| | - Reza Sabbagh
- Department of Mechanical Engineering, University of Alberta, Edmonton, Canada
| | - Darren H. Freed
- Departments of Surgery, Physiology & Biomedical Engineering, University of Alberta, Edmonton, Canada
| | - David S. Nobes
- Department of Mechanical Engineering, University of Alberta, Edmonton, Canada
- * E-mail:
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31
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Messer S, Cernic S, Page A, Berman M, Kaul P, Colah S, Ali J, Pavlushkov E, Baxter J, Quigley R, Osman M, Nachum E, Parameshwar J, Abu-Omar Y, Dunning J, Goddard M, Bhagra S, Pettit S, Cheshire C, Lewis C, Kydd A, Ali A, Sudarshan C, Jenkins D, Tsui S, Hall R, Catarino P, Large SR. A 5-year single-center early experience of heart transplantation from donation after circulatory-determined death donors. J Heart Lung Transplant 2020; 39:1463-1475. [PMID: 33248525 DOI: 10.1016/j.healun.2020.10.001] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND In an effort to address the increasing demand for heart transplantation within the United Kingdom (UK), we established a clinical program of heart transplantation from donation after circulatory-determined death (DCD) donors in 2015. After 5 years, we report the clinical early outcomes and impact of the program. METHODS This is a single-center, retrospective, matched, observational cohort study comparing outcomes of hearts transplanted from DCD donors from March 1, 2015 to February 29, 2020 with those from matched donation after brain death (DBD) donors at Royal Papworth Hospital (RPH) (Cambridge, UK). DCD hearts were either retrieved using thoracoabdominal normothermic regional perfusion or the direct procurement and perfusion technique. All DBD hearts were procured using standard cold static storage. The primary outcomes were recipient 30-day and 1-year survival. RESULTS During the 5-year study, DCD heart donation increased overall heart transplant activity by 48% (79 for DCD and 164 for DBD). There was no difference in survival at 30 days (97% for DCD vs 99% for DBD, p = 1.00) or 1 year (91% for DCD vs 89% for DBD, p = 0.72). There was no difference in the length of stay in the intensive care unit (7 for DCD vs 6 for DBD days, p = 0.24) or in the hospital (24 for DCD vs 25 for DBD days, p = 0.84). CONCLUSIONS DCD heart donation increased overall heart transplant activity at RPH by 48%, with no difference in 30-day or 1-year survival in comparison with conventional DBD heart transplantations. DCD heart donation is set to make a dramatic difference in the number of patients who can benefit from heart transplantation.
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Affiliation(s)
- Simon Messer
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Sendi Cernic
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Aravinda Page
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Marius Berman
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Pradeep Kaul
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Simon Colah
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Jason Ali
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Evgeny Pavlushkov
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Jen Baxter
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Richard Quigley
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Mohamed Osman
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Eyal Nachum
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Jayan Parameshwar
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Yasir Abu-Omar
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - John Dunning
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Martin Goddard
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Sai Bhagra
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Stephen Pettit
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Caitlin Cheshire
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Clive Lewis
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Anna Kydd
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Ayyaz Ali
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Catherine Sudarshan
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - David Jenkins
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Steven Tsui
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Roger Hall
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Pedro Catarino
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Stephen R Large
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
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32
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Primed Left Ventricle Heart Perfusion Creates Physiological Aortic Pressure in Porcine Hearts. ASAIO J 2020; 66:55-63. [PMID: 30893130 DOI: 10.1097/mat.0000000000000947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
This article presents a primed left ventricle heart perfusion method to generate physiologic aortic pressure (AoP) and perform functional assessment. Isolated hearts of male Yorkshire pigs were used to study the hemodynamic behaviors of AoPs generated in the primed left ventricle heart perfusion (n = 6) and conventional (zero-loaded left ventricle) Langendorff perfusion (n = 6). The measurement results show that left ventricular pressure generated in the primed left ventricle heart perfusion is a determinant of physiologic AoP (i.e. systolic and diastolic pressures within physiologic range). The aortic pulse pressure (systolic pressure = 124.5 ± 1.7 mm Hg, diastolic pressure = 87.8 ± 0.9 mm Hg, aortic pulse pressure = 36.7 ± 2.6 mm Hg) from the primed left ventricle heart perfusion represents close match with the in vivo physiologic data. The volume in the left ventricle remains constant throughout the primed left ventricle heart perfusion, which allows us to perform isovolumetric left ventricular pressure measurement in ex vivo heart perfusion (EVHP). Left ventricular contractility measurements (maximum and minimum rates of left ventricular pressure change) were derived for cardiac assessment. In summary, the proposed primed left ventricle heart perfusion method is able to create physiologic AoP and enables left ventricular functional assessment in EVHP in porcine hearts.
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33
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Ribeiro RVP, Alvarez JS, Yu F, Adamson MB, Paradiso E, Hondjeu ARM, Xin L, Gellner B, Degen M, Bissoondath V, Meineri M, Rao V, Badiwala MV. Comparing Donor Heart Assessment Strategies During Ex Situ Heart Perfusion to Better Estimate Posttransplant Cardiac Function. Transplantation 2020; 104:1890-1898. [PMID: 32826843 DOI: 10.1097/tp.0000000000003374] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Ex situ heart perfusion (ESHP) limits ischemic periods and enables continuous monitoring of donated hearts; however, a validated assessment method to predict cardiac performance has yet to be established. We compare biventricular contractile and metabolic parameters measured during ESHP to determine the best evaluation strategy to estimate cardiac function following transplantation. METHODS Donor pigs were assigned to undergo beating-heart donation (n = 9) or donation after circulatory death (n = 8) induced by hypoxia. Hearts were preserved for 4 hours with ESHP while invasive and noninvasive (NI) biventricular contractile, and metabolic assessments were performed. Following transplantation, hearts were evaluated at 3 hours of reperfusion. Spearman correlation was used to determine the relationship between ESHP parameters and posttransplant function. RESULTS We performed 17 transplants; 14 successfully weaned from bypass (beating-heart donation versus donation after circulatory death; P = 0.580). Left ventricular invasive preload recruitable stroke work (PRSW) (r = 0.770; P = 0.009), NI PRSW (r = 0.730; P = 0.001), and NI maximum elastance (r = 0.706; P = 0.002) strongly correlated with cardiac index (CI) following transplantation. Right ventricular NI PRSW moderately correlated to CI following transplantation (r = 0.688; P = 0.003). Lactate levels were weakly correlated with CI following transplantation (r = -0.495; P = 0.043). None of the echocardiography measurements correlated with cardiac function following transplantation. CONCLUSIONS Left ventricular functional parameters, especially ventricular work and reserve, provided the best estimation of myocardial performance following transplantation. Furthermore, simple NI estimates of ventricular function proved useful in this setting. Right ventricular and metabolic measurements were limited in their ability to correlate with myocardial recovery. This emphasizes the need for an ESHP platform capable of assessing myocardial contractility and suggests that metabolic parameters alone do not provide a reliable evaluation.
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Affiliation(s)
- Roberto Vanin Pinto Ribeiro
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Juglans Souto Alvarez
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Frank Yu
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Mitchell Brady Adamson
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Emanuela Paradiso
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Arnaud Romeo Mbadjeu Hondjeu
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Liming Xin
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Mechanical Engineering, University of Toronto, Toronto, Canada
| | - Bryan Gellner
- Department of Mechanical Engineering, University of Toronto, Toronto, Canada
| | - Maja Degen
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Ved Bissoondath
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Massimiliano Meineri
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Mitesh Vallabh Badiwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Canada
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Guariento A, Doulamis IP, Duignan T, Kido T, Regan WL, Saeed MY, Hoganson DM, Emani SM, Fynn-Thompson F, Matte GS, Del Nido PJ, McCully JD. Mitochondrial transplantation for myocardial protection in ex-situ‒perfused hearts donated after circulatory death. J Heart Lung Transplant 2020; 39:1279-1288. [PMID: 32703639 DOI: 10.1016/j.healun.2020.06.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Donation after circulatory death (DCD) offers an additional source of cardiac allografts, potentially allowing expansion of the donor pool, but is limited owing to the effects of ischemia. In this study, we investigated the efficacy of mitochondrial transplantation to enhance myocardial function of DCD hearts. METHODS Circulatory death was induced in Yorkshire pigs (40-50 kg, n = 29) by a cessation of mechanical ventilation. After 20 minutes of warm ischemia, cardioplegia was administered. The hearts were then reperfused on an ex-situ blood perfusion system. After 15 minutes of reperfusion, hearts received either vehicle alone (vehicle [VEH], 10 ml; n = 8) or vehicle containing autologous mitochondria (vehicle with mitochondria as a single injection [MT], 5 × 109 in 10 ml, n = 8). Another group of hearts (serial injection of mitochondria [MTS]; n = 6) received a second injection of mitochondria (5 × 109 in 10 ml) after 2 hours of ex-situ heart perfusion and reperfused for an additional 2 hours. A Sham group (sham hearts; n = 6) did not undergo any warm ischemia. RESULTS At the end of 4 hours of reperfusion, MT and MTS groups showed a significantly increased left ventricle/ventricular peak developed pressure (p = 0.002), maximal left ventricle/ventricular pressure rise (p < 0.001), fractional shortening (p < 0.001), and myocardial oxygen consumption (p = 0.004) compared with VEH. Infarct size was significantly decreased in MT and MTS groups compared with VEH (p < 0.001). No differences were found in arterial lactate levels among or within groups throughout reperfusion. CONCLUSIONS Mitochondrial transplantation significantly preserves myocardial function and oxygen consumption in DCD hearts, thus providing a possible option for expanding the heart donor pool.
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Affiliation(s)
- Alvise Guariento
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ilias P Doulamis
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas Duignan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Takashi Kido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William L Regan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mossab Y Saeed
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - James D McCully
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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35
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Hatami S, White CW, Qi X, Buchko M, Ondrus M, Kinnear A, Himmat S, Sergi C, Nagendran J, Freed DH. Immunity and Stress Responses Are Induced During Ex Situ Heart Perfusion. Circ Heart Fail 2020; 13:e006552. [PMID: 32498623 DOI: 10.1161/circheartfailure.119.006552] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ex situ heart perfusion (ESHP) preserves the donated heart in a perfused, beating condition preventing cold storage-related ischemia and provides a platform to evaluate myocardial viability during preservation. However, myocardial function declines gradually during ESHP. Extracorporeal circulation systems are associated with the induction of systemic inflammatory and stress responses. Our aim was to evaluate the incidence of inflammation and induction of endoplasmic reticulum stress responses during an extended period of ESHP. METHODS Cardiac function, myocardial tissue injury, markers of inflammation, oxidative stress, and endoplasmic reticulum stress were assessed in healthy pig hearts, perfused for 12 hours either in nonworking mode (non-WM=7) or working mode (WM, n=6). RESULTS Cardiac function declined during ESHP but was significantly better preserved in the hearts perfused in WM (median 11-hour cardiac index/1-hour cardiac index: WM=27% versus non-WM=9.5%, P=0.022). Myocardial markers of endoplasmic reticulum stress were expressed higher in ESHP hearts compared with in vivo samples. The proinflammatory cytokines and oxidized low-density lipoprotein significantly increased in the perfusate throughout the perfusion in both perfusion groups. The left ventricular expression of the cytokines and malondialdehyde was induced in non-WM, whereas it was not different between WM and in vivo. CONCLUSIONS Myocardial function declines during ESHP regardless of perfusion mode. However, ESHP in WM may lead to superior preservation of myocardial function and viability. Both inflammation and endoplasmic reticulum stress responses are significantly induced during ESHP and may contribute to the myocardial functional decline, representing a potential therapeutic target to improve the clinical donor heart preservation.
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Affiliation(s)
- Sanaz Hatami
- Departments of Surgery (S. Hatami, X.Q., M.B., M.O., A.K., S. Himmat, J.N., D.H.F.), University of Alberta, Edmonton, Canada.,Canadian Transplant Research Program (S. Hatami, X.Q., S. Himmat, J.N., D.H.F.)
| | | | - Xiao Qi
- Departments of Surgery (S. Hatami, X.Q., M.B., M.O., A.K., S. Himmat, J.N., D.H.F.), University of Alberta, Edmonton, Canada.,Canadian Transplant Research Program (S. Hatami, X.Q., S. Himmat, J.N., D.H.F.)
| | - Max Buchko
- Departments of Surgery (S. Hatami, X.Q., M.B., M.O., A.K., S. Himmat, J.N., D.H.F.), University of Alberta, Edmonton, Canada
| | - Martin Ondrus
- Departments of Surgery (S. Hatami, X.Q., M.B., M.O., A.K., S. Himmat, J.N., D.H.F.), University of Alberta, Edmonton, Canada
| | - Alexandra Kinnear
- Departments of Surgery (S. Hatami, X.Q., M.B., M.O., A.K., S. Himmat, J.N., D.H.F.), University of Alberta, Edmonton, Canada
| | - Sayed Himmat
- Departments of Surgery (S. Hatami, X.Q., M.B., M.O., A.K., S. Himmat, J.N., D.H.F.), University of Alberta, Edmonton, Canada.,Canadian Transplant Research Program (S. Hatami, X.Q., S. Himmat, J.N., D.H.F.)
| | - Consolato Sergi
- Laboratory Medicine and Pathology (C.S.), University of Alberta, Edmonton, Canada
| | - Jayan Nagendran
- Departments of Surgery (S. Hatami, X.Q., M.B., M.O., A.K., S. Himmat, J.N., D.H.F.), University of Alberta, Edmonton, Canada.,Alberta Transplant Institute, Edmonton, Canada (J.N., D.N.F.).,Canadian Transplant Research Program (S. Hatami, X.Q., S. Himmat, J.N., D.H.F.)
| | - Darren H Freed
- Departments of Surgery (S. Hatami, X.Q., M.B., M.O., A.K., S. Himmat, J.N., D.H.F.), University of Alberta, Edmonton, Canada.,Physiology (D.H.F.), University of Alberta, Edmonton, Canada.,Biomedical Engineering (D.H.F.), University of Alberta, Edmonton, Canada.,Alberta Transplant Institute, Edmonton, Canada (J.N., D.N.F.).,Canadian Transplant Research Program (S. Hatami, X.Q., S. Himmat, J.N., D.H.F.)
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36
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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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37
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Vela RJ, Jessen ME, Peltz M. Ice, ice, maybe? Is it time to ditch the igloo cooler? Benefits of machine perfusion preservation of donor hearts. Artif Organs 2019; 44:220-227. [DOI: 10.1111/aor.13599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Ryan J. Vela
- Department of Cardiovascular and Thoracic Surgery University of Texas Southwestern Medical Center Dallas Texas
| | - Michael E. Jessen
- Department of Cardiovascular and Thoracic Surgery University of Texas Southwestern Medical Center Dallas Texas
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery University of Texas Southwestern Medical Center Dallas Texas
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38
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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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39
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Gellner B, Xin L, Ribeiro RVP, Bissoondath V, Lu P, Adamson MB, Yu F, Paradiso E, Zu J, Simmons CA, Badiwala MV. The Implementation of an Adjustable Afterload Module for Ex Situ Heart Perfusion. Cardiovasc Eng Technol 2019; 11:96-110. [PMID: 31797263 DOI: 10.1007/s13239-019-00447-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/24/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Windkessel impedance analysis has proven to be an effective technique for instituting artificial afterload on ex situ hearts. Traditional fixed parameter afterload modules, however, are unable to handle the changing contractile conditions associated with prolonged ex situ heart perfusion. In this paper, an adjustable afterload module is described comprising of three fully adjustable sub-components: a systemic resistor, a proximal resistor and a compliance chamber. METHODS Using a centrifugal pump, the systemic resistor and compliance chamber were subjected to testing across their operating ranges, whereby the predictability of resistance and compliance values was evaluated. The components were then assembled, and the full module tested on three separate porcine hearts perfused for 6 h with success defined by the ability to maintain physiological systolic and diastolic aortic pressures across flow rate variability. RESULTS For both the systemic resistor and compliance chamber, experimental measurements agreed with their theoretical equivalents, with coefficients of determination of 0.99 and 0.97 for the systemic resistor and compliance chamber, respectively. During ex situ perfusion, overall 95% confidence intervals demonstrate that physiological systolic (95-96.21 mmHg) and diastolic (26.8-28.8 mmHg) pressures were successfully maintained, despite large variability in aortic flow. Left ventricular contractile parameters, were found to be in line with those in previous studies, suggesting the afterload module has no detrimental impact on functional preservation. CONCLUSIONS We conclude that due to the demonstrable control of our afterload module, we can maintain physiological aortic pressures in a passive afterload working mode across prolonged perfusion periods, enabling effective perfusion regardless of contractile performance.
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Affiliation(s)
- Bryan Gellner
- Department of Mechanical & Industrial Engineering, University of Toronto, Toronto, ON, Canada
- Translational Biology & Engineering Program, Ted Rogers Centre for Heart Research, Toronto, ON, Canada
| | - Liming Xin
- Department of Mechanical & Industrial Engineering, University of Toronto, Toronto, ON, Canada
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- State Key Laboratory of Mechanical Transmissions, Chongqing University, Chongqing, China
| | - Roberto Vanin Pinto Ribeiro
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ved Bissoondath
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Pengzhou Lu
- Department of Mechanical & Industrial Engineering, University of Toronto, Toronto, ON, Canada
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Mitchell B Adamson
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Frank Yu
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Emanuela Paradiso
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Jean Zu
- Department of Mechanical & Industrial Engineering, University of Toronto, Toronto, ON, Canada
| | - Craig A Simmons
- Department of Mechanical & Industrial Engineering, University of Toronto, Toronto, ON, Canada.
- Translational Biology & Engineering Program, Ted Rogers Centre for Heart Research, Toronto, ON, Canada.
- Institute of Biomaterials & Biomedical Engineering, University of Toronto, Toronto, ON, Canada.
| | - Mitesh V Badiwala
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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40
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Gellner B, Xin L, Pinto Ribeiro RV, Bissoondath V, Adamson MB, Yu F, Lu P, Paradiso E, Mbadjeu Hondjeu AR, Simmons CA, Badiwala MV. The implementation of physiological afterload during ex situ heart perfusion augments prediction of posttransplant function. Am J Physiol Heart Circ Physiol 2019; 318:H25-H33. [PMID: 31774696 DOI: 10.1152/ajpheart.00427.2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Ex situ heart perfusion (ex situ heart perfusion) is an emerging technique that aims to increase the number of organs available for transplantation by augmenting both donor heart preservation and evaluation. Traditionally, ex situ heart perfusion has been performed in an unloaded Langendorff mode, though more recently groups have begun to use pump-supported working mode (PSWM) and passive afterload working mode (PAWM) to enable contractile evaluation during ex situ heart perfusion. To this point, however, neither the predictive effectiveness of the two working modes nor the predictive power of individual contractile parameters has been analyzed. In this article, we use our previously described system to analyze the predictive relevance of a multitude of contractile parameters measured in each working mode. Ten porcine hearts were excised and perfused ex situ in Langendorff mode for 4 h, evaluated using pressure-volume catheterization in both PSWM and PAWM, and transplanted into size-matched recipient pigs. After 3 h, hearts were weaned from cardiopulmonary bypass and evaluated. When correlating posttransplant measurements to their ex situ counterparts, we report that parameters measured in both modes show sufficient power (Spearman rank coefficient > 0.7) in predicting global posttransplant function, characterized by cardiac index and preload recruitable stroke work. For the prediction of specific posttransplant systolic and diastolic function, however, a large discrepancy between the two working modes was observed. With 9 of 10 measured posttransplant parameters showing stronger correlation with counterparts measured in PAWM, it is concluded that PAWM allows for a more detailed and nuanced prediction of posttransplant function than can be made in PSWM.NEW & NOTEWORTHY Ex situ heart perfusion has been proposed as a means to augment the organ donor pool by improving organ preservation and evaluation between donation and transplantation. Using our multimodal perfusion system, we analyzed the impact of using a "passive afterload working mode" for functional evaluation as compared with the more traditional "pump-supported working mode." Our data suggests that passive afterload working mode allows for a more nuanced prediction of posttransplant function in porcine hearts.
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Affiliation(s)
- Bryan Gellner
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada.,Translational Biology and Engineering Program, Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
| | - Liming Xin
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Roberto Vanin Pinto Ribeiro
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Ved Bissoondath
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mitchell B Adamson
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Frank Yu
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Pengzhou Lu
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Emanuela Paradiso
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Arnaud Romeo Mbadjeu Hondjeu
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Craig A Simmons
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada.,Translational Biology and Engineering Program, Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Mitesh V Badiwala
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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41
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Zhalmuratova D, La TG, Yu KTT, Szojka ARA, Andrews SHJ, Adesida AB, Kim CI, Nobes DS, Freed DH, Chung HJ. Mimicking "J-Shaped" and Anisotropic Stress-Strain Behavior of Human and Porcine Aorta by Fabric-Reinforced Elastomer Composites. ACS APPLIED MATERIALS & INTERFACES 2019; 11:33323-33335. [PMID: 31464413 DOI: 10.1021/acsami.9b10524] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
An ex vivo heart perfusion device preserves the donor heart in a warm beating state during transfer between extraction and implantation surgeries. One of the current challenges includes the use of rigid and noncompliant plastic tubes, which causes injuries to the heart at the junction between the tissue and the tube. The compliant and rapidly strain-stiffening mechanical property that generates a "J-shaped" stress-strain behavior is necessary for producing the Windkessel effect, which ensures continuous flow of blood through the aorta. In this study, we mimic the J-shaped and anisotropic stress-strain behavior of human aorta in synthetic elastomers to replace the problematic noncompliant plastic tube. First, we assess the mechanical properties of human (n = 1) and porcine aorta (n = 14) to quantify the nonlinear and anisotropic behavior under uniaxial tensile stress from five different regions of the aorta. Second, fabric-reinforced elastomer composites were prepared by reinforcing silicone elastomers with embedded fabrics in a trilayer geometry. The knitted structures of the fabric provide strain-stiffening as well as anisotropic mechanical properties of the resulting composite in a deterministic manner. By optimizing the combination between different elastomers and fabrics, the resulting composites matched the J-shaped and anisotropic stress-strain behavior of natural human and porcine aorta. Finally, improved analytical constitutive models based on Gent's and Mooney-Rivlin's constitutive model (to describe the elastomer matrix) combined with Holzapfel-Gasser-Ogden's model (to represent the stiffer fabrics) were developed to describe the J-shaped behavior of the natural aortas and the fabric-reinforced composites. We anticipate that the suggested fabric-reinforced silicone elastomer composite design concept can be used to develop complex soft biomaterials, as well as in emerging engineering fields such as soft robotics and microfluidics, where the Windkessel effect can be useful in regulating the flow of fluids.
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Affiliation(s)
| | | | | | - Alexander R A Szojka
- Department of Surgery , University of Alberta , Edmonton , Alberta T6G 2E1 , Canada
| | - Stephen H J Andrews
- Department of Surgery , University of Alberta , Edmonton , Alberta T6G 2E1 , Canada
| | - Adetola B Adesida
- Department of Surgery , University of Alberta , Edmonton , Alberta T6G 2E1 , Canada
| | | | | | - Darren H Freed
- Department of Surgery , University of Alberta , Edmonton , Alberta T6G 2E1 , Canada
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Ergebnisse der Transplantation von Spenderherzen nach normothermer Ex-vivo-Perfusion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-018-0264-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Hearts Donated After Circulatory Death and Reconditioned Using Normothermic Regional Perfusion Can Be Successfully Transplanted Following an Extended Period of Static Storage. Circ Heart Fail 2019; 12:e005364. [DOI: 10.1161/circheartfailure.118.005364] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Hatami S, White CW, Shan S, Haromy A, Qi X, Ondrus M, Kinnear A, Himmat S, Michelakis E, Nagendran J, Freed DH. Myocardial Functional Decline During Prolonged Ex Situ Heart Perfusion. Ann Thorac Surg 2019; 108:499-507. [PMID: 30872100 DOI: 10.1016/j.athoracsur.2019.01.076] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 12/14/2018] [Accepted: 01/21/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Myocardial function declines in a time-dependent fashion during ex situ heart perfusion. Cell death and metabolic alterations may contribute to this phenomenon, limiting the safe perfusion period and the potential of ex situ heart perfusion to expand the donor pool. Our aim was to investigate the etiology of myocardial functional decline in ex situ perfused hearts. METHODS Cardiac function, apoptosis, effectors and markers of cell death, and metabolic function were assessed in healthy pig hearts perfused for 12 hours. These hearts were perfused in nonworking mode or working mode. RESULTS Cardiac function declined during ex situ heart perfusion regardless of perfusion mode but was significantly better preserved in the hearts perfused in working mode (11-hour cardiac index/1-hour cardiac index: working mode, 33%; nonworking mode, 10%; p = 0.025). The rate of apoptosis was higher in the ex situ perfused hearts compared with in vivo samples (apoptotic cells: in vivo, 0.13%; working mode, 0.54%; nonworking mode, 0.88%; p < 0.001), but the absolute values were low and out of proportion to the decline in function in either group. Myocardial dysfunction at the end of the perfusion interval was partially rescued by delivery of a pyruvate bolus. CONCLUSIONS A significant decline in myocardial function occurs over time in hearts preserved ex situ that is out of proportion to the magnitude of myocyte cell death present in dysfunctional hearts. Alterations in myocardial substrate utilization during prolonged ex situ heart perfusion may contribute to this phenomenon and represent an avenue to improve donor heart preservation.
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Affiliation(s)
- Sanaz Hatami
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Canadian Transplant Research Program, Canada
| | - Christopher W White
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Canadian Transplant Research Program, Canada
| | - Shubham Shan
- Department of Physiology, University of Alberta, Edmonton, Alberta, Canada
| | - Alois Haromy
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Xiao Qi
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Canadian Transplant Research Program, Canada
| | - Martin Ondrus
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Alexandra Kinnear
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Sayed Himmat
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Canadian Transplant Research Program, Canada
| | | | - Jayan Nagendran
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Canadian Transplant Research Program, Canada; Alberta Transplant Institute, Edmonton, Alberta, Canada
| | - Darren H Freed
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Canadian Transplant Research Program, Canada; Department of Physiology, University of Alberta, Edmonton, Alberta, Canada; Alberta Transplant Institute, Edmonton, Alberta, Canada; Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada.
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Enhanced myocardial protection in cardiac donation after circulatory death using Intralipid® postconditioning in a porcine model. Can J Anaesth 2019; 66:672-685. [DOI: 10.1007/s12630-019-01322-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/23/2018] [Accepted: 12/14/2018] [Indexed: 01/07/2023] Open
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Wyss RK, Méndez-Carmona N, Sanz MN, Arnold M, Segiser A, Fiedler GM, Carrel TP, Djafarzadeh S, Tevaearai Stahel HT, Longnus SL. Mitochondrial integrity during early reperfusion in an isolated rat heart model of donation after circulatory death-consequences of ischemic duration. J Heart Lung Transplant 2018; 38:647-657. [PMID: 30655178 DOI: 10.1016/j.healun.2018.12.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/13/2018] [Accepted: 12/18/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Cardioprotection and graft evaluation after ischemia-reperfusion (IR) are essential in facilitating heart transplantation with donation after circulatory death. Given the key role of mitochondria in IR, we aimed to investigate the tolerance of cardiac mitochondria to warm, global ischemia and to determine the predictive value of early reperfusion mitochondria-related parameters for post-ischemic cardiac recovery. METHODS Isolated, working rat hearts underwent 0, 21, 24, 27, 30, or 33 minutes of warm, global ischemia, followed by 60 minutes of reperfusion. Functional recovery (developed pressure × heart rate) was determined at 60 minutes of reperfusion, whereas mitochondrial integrity was measured at 10 minutes of reperfusion. RESULTS Functional recovery at 60 minutes of reperfusion decreased with ≥ 27 minutes of ischemia vs no ischemia (n = 7-8/group; p < 0.01). Cytochrome c, succinate release, and mitochondrial Ca2+ content increased with ≥ 27 minutes of ischemia vs no ischemia (p < 0.05). Ischemia at ≥ 21 minutes decreased mitochondrial coupling, adenosine 5'-triphosphate content, mitochondrial Ca2+ retention capacity, and increased oxidative damage vs no ischemia (p < 0.05). Reactive oxygen species (ROS) from reverse electron transfer increased with 21 and 27 minutes of ischemia vs no ischemia and 33 minutes of ischemia (p < 0.05), whereas ROS from forward electron transfer increased only with 33 minutes of ischemia vs no ischemia (p < 0.05). Mitochondrial coupling and adenosine 5'-triphosphate content correlated positively and cytochrome c, succinate, oxidative damage, and mitochondrial Ca2+ content correlated negatively with cardiac functional recovery (p < 0.05). CONCLUSIONS Mitochondrial dysfunction occurs with shorter periods of ischemia than cardiac dysfunction. Mitochondrial coupling, ROS emission from reverse electron transfer, and calcium retention are particularly sensitive to early reperfusion injury, reflecting potential targets for cardioprotection. Indicators of mitochondrial integrity may be of aid in evaluating suitability of donation after circulatory death grafts for transplantation.
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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-Nieves Sanz
- 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
| | - Georg M Fiedler
- Center of Laboratory Medicine, University Institute of Clinical Chemistry, Bern, Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland; Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Siamak Djafarzadeh
- Department for BioMedical Research, University of Bern, Bern, Switzerland; Department of Intensive Care Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Hendrik T Tevaearai Stahel
- 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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White CW, Messer SJ, Large SR, Conway J, Kim DH, Kutsogiannis DJ, Nagendran J, Freed DH. Transplantation of Hearts Donated after Circulatory Death. Front Cardiovasc Med 2018; 5:8. [PMID: 29487855 PMCID: PMC5816942 DOI: 10.3389/fcvm.2018.00008] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 01/19/2018] [Indexed: 12/17/2022] Open
Abstract
Cardiac transplantation has become limited by a critical shortage of suitable organs from brain-dead donors. Reports describing the successful clinical transplantation of hearts donated after circulatory death (DCD) have recently emerged. Hearts from DCD donors suffer significant ischemic injury prior to organ procurement; therefore, the traditional approach to the transplantation of hearts from brain-dead donors is not applicable to the DCD context. Advances in our understanding of ischemic post-conditioning have facilitated the development of DCD heart resuscitation strategies that can be used to minimize ischemia-reperfusion injury at the time of organ procurement. The availability of a clinically approved ex situ heart perfusion device now allows DCD heart preservation in a normothermic beating state and minimizes exposure to incremental cold ischemia. This technology also facilitates assessments of organ viability to be undertaken prior to transplantation, thereby minimizing the risk of primary graft dysfunction. The application of a tailored approach to DCD heart transplantation that focuses on organ resuscitation at the time of procurement, ex situ preservation, and pre-transplant assessments of organ viability has facilitated the successful clinical application of DCD heart transplantation. The transplantation of hearts from DCD donors is now a clinical reality. Investigating ways to optimize the resuscitation, preservation, evaluation, and long-term outcomes is vital to ensure a broader application of DCD heart transplantation in the future.
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Affiliation(s)
| | - Simon J Messer
- Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Stephen R Large
- Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Daniel H Kim
- Cardiology, University of Alberta, Edmonton, AB, Canada
| | | | - Jayan Nagendran
- Cardiac Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H Freed
- Cardiac Surgery, University of Alberta, Edmonton, AB, Canada.,Department of Physiology, University of Alberta, Edmonton, AB, Canada.,Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
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Vasanthan V, Fedak PWM. Seeing a tree through the forest: Precision medicine tools can enhance donor allocation in heart transplantation. J Thorac Cardiovasc Surg 2018; 155:1591-1592. [PMID: 29310930 DOI: 10.1016/j.jtcvs.2017.12.008] [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: 11/18/2017] [Accepted: 12/01/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Vishnu Vasanthan
- Section of Cardiac Surgery, Department of Cardiac Science, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
| | - Paul W M Fedak
- Section of Cardiac Surgery, Department of Cardiac Science, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada.
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A New Multi-Mode Perfusion System for Ex Vivo Heart Perfusion Study. J Med Syst 2017; 42:25. [PMID: 29273867 DOI: 10.1007/s10916-017-0882-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
Abstract
Ex vivo heart perfusion has been shown to be an effective means of facilitating the resuscitation and assessment of donor hearts for cardiac transplantation. Over the last ten years however, only a few ex vivo perfusion systems have been developed for this application. While results have been promising, a system capable of facilitating multiple perfusion strategies on the same platform has not yet been realized. In this paper, the design, development and testing of a novel and modular ex vivo perfusion system is described. The system is capable of operating in three unique primary modes: the traditional Langendorff Mode, Pump-Supported Working-Mode, and Passive Afterload Working-Mode. In each mode, physiological hemodynamic parameters can be produced by managing perfusion settings. To evaluate heart viability, six experiments were conducted using porcine hearts and measuring several parameters including: pH, aortic pressure, lactate metabolism, coronary vascular resistance (CVR), and myocardial oxygen consumption. Pressure-volume relationship measurements were used to assess left ventricular contractility in each Working Mode. Hemodynamic and metabolic conditions remained stable and consistent across 4 h of ex vivo heart perfusion on the ex vivo perfusion system, validating the system as a viable platform for future development of novel preservation and assessment strategies.
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