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Cui EY, Gouchoe DA, Salmon-Rekhi ST, Whitson BA, Black SM. An Unexpected Partnership: Alexis Carrel, Charles Lindbergh, and Normothermic Machine Perfusion. ASAIO J 2024:00002480-990000000-00459. [PMID: 38595100 DOI: 10.1097/mat.0000000000002205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Organ transplantation is a triumph of modern medicine which represents a culmination of science and imagination, saving thousands of lives a year. However, transplantation is severely limited by suitable donor allografts. To expand the donor pool and make transplantation achievable for all, normothermic machine perfusion (NMP) is being employed more frequently. Normothermic machine perfusion involves the utilization of a device to approximate the physiology of the human body, preserve organs outside of the donor, and provide a dynamic assessment platform to determine organ suitability for transplantation. As NMP technology advances, it will soon be possible to genetically modify and actively repair these organs. Although its application to the field of transplantation is relatively new, the concept, foundation, and development of NMP can be traced back to the pioneering work of the surgeon-scientist, Alexis Carrel and the famous aviator, Charles Lindbergh in the 1930s. Their collaboration resulted in the Carrel-Lindbergh Perfusion device, an early perfusion device that was able to keep organs alive ex vivo for weeks and is most appropriately viewed as a precursor to modern machine perfusion technologies. As NMP technology becomes more advanced and refined, it is important to acknowledge the historical context in which these technologies emerged.
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Affiliation(s)
- Ervin Y Cui
- From the Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Doug A Gouchoe
- From the Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
- Department of Surgery, The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Suhavi T Salmon-Rekhi
- Department of Surgery, The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- From the Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
- Department of Surgery, The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sylvester M Black
- From the Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
- Department of Surgery, The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Department of Surgery, Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Paolucci I, Bulatović M, Weber S, Tinguely P. Thermal ablation with configurable shapes: a comprehensive, automated model for bespoke tumor treatment. Eur Radiol Exp 2023; 7:67. [PMID: 37932631 PMCID: PMC10628015 DOI: 10.1186/s41747-023-00381-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/29/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Malignant tumors routinely present with irregular shapes and complex configurations. The lack of customization to individual tumor shapes and standardization of procedures limits the success and application of thermal ablation. METHODS We introduced an automated treatment model consisting of (i) trajectory and ablation profile planning, (ii) ablation probe insertion, (iii) dynamic energy delivery (including robotically driven control of the energy source power and location over time, according to a treatment plan bespoke to the tumor shape), and (iv) quantitative ablation margin verification. We used a microwave ablation system and a liver phantom (acrylamide polymer with a thermochromic ink) to mimic coagulation and measure the ablation volume. We estimated the ablation width as a function of power and velocity following a probabilistic model. Four representative shapes of liver tumors < 5 cm were selected from two publicly available databases. The ablated specimens were cut along the ablation probe axis and photographed. The shape of the ablated volume was extracted using a color-based segmentation method. RESULTS The uncertainty (standard deviation) of the ablation width increased with increasing power by ± 0.03 mm (95% credible interval [0.02, 0.043]) per watt increase in power and by ± 0.85 mm (95% credible interval [0, 2.5]) per mm/s increase in velocity. Continuous ablation along a straight-line trajectory resulted in elongated rotationally symmetric ablation shapes. Simultaneous regulation of the power and/or translation velocity allowed to modulate the ablation width at specific locations. CONCLUSIONS This study offers the proof-of-principle of the dynamic energy delivery system using ablation shapes from clinical cases of malignant liver tumors. RELEVANCE STATEMENT The proposed automated treatment model could favor the customization and standardization of thermal ablation for complex tumor shapes. KEY POINTS • Current thermal ablation systems are limited to ellipsoidal or spherical shapes. • Dynamic energy delivery produces elongated rotationally symmetric ablation shapes with varying widths. • For complex tumor shapes, multiple customized ablation shapes could be combined.
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Affiliation(s)
- Iwan Paolucci
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland.
| | - Milica Bulatović
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Stefan Weber
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Pascale Tinguely
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
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Risbey CWG, Pulitano C. Normothermic Ex Vivo Machine Perfusion for Liver Transplantation: A Systematic Review of Progress in Humans. J Clin Med 2023; 12:jcm12113718. [PMID: 37297913 DOI: 10.3390/jcm12113718] [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: 04/19/2023] [Revised: 05/16/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Liver transplantation is a lifesaving procedure for patients with end-stage liver disease (ESLD). However, many patients never receive a transplant due to insufficient donor supply. Historically, organs have been preserved using static cold storage (SCS). However, recently, ex vivo normothermic machine perfusion (NMP) has emerged as an alternative technique. This paper aims to investigate the clinical progress of NMP in humans. METHODS Papers evaluating the clinical outcomes of NMP for liver transplantation in humans were included. Lab-based studies, case reports, and papers utilizing animal models were excluded. Literature searches of MEDLINE and SCOPUS were conducted. The revised Cochrane risk-of-bias tool for randomised trials (RoB 2) and the risk of bias in nonrandomised studies for interventions (ROBINS-I) tools were used. Due to the heterogeneity of the included papers, a meta-analysis was unable to be completed. RESULTS In total, 606 records were identified, with 25 meeting the inclusion criteria; 16 papers evaluated early allograft dysfunction (EAD) with some evidence for lower rates using NMP compared to SCS; 19 papers evaluated patient or graft survival, with no evidence to suggest superior outcomes with either NMP or SCS; 10 papers evaluated utilization of marginal and donor after circulatory death (DCD) grafts, with good evidence to suggest NMP is superior to SCS. CONCLUSIONS There is good evidence to suggest that NMP is safe and that it likely affords clinical advantages to SCS. The weight of evidence supporting NMP is growing, and this review found the strongest evidence in support of NMP to be its capacity to increase the utilization rates of marginal and DCD allografts.
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Affiliation(s)
- Charles W G Risbey
- Department of Surgery, Royal Prince Alfred Hospital, Sydney 2050, Australia
- Centre for Organ Assessment, Repair & Optimization (COARO), Sydney 2050, Australia
- Central Clinical School, The University of Sydney, Sydney 2006, Australia
| | - Carlo Pulitano
- Centre for Organ Assessment, Repair & Optimization (COARO), Sydney 2050, Australia
- Central Clinical School, The University of Sydney, Sydney 2006, Australia
- Department of Transplant Surgery, Royal Prince Alfred Hospital, Sydney 2050, Australia
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Kanani T, Isherwood J, Issa E, Chung WY, Ravaioli M, Oggioni MR, Garcea G, Dennison A. A Narrative Review of the Applications of Ex-vivo Human Liver Perfusion. Cureus 2023; 15:e34804. [PMID: 36915839 PMCID: PMC10008027 DOI: 10.7759/cureus.34804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/11/2023] Open
Abstract
Ex-vivo perfusion describes the extra-corporeal delivery of fluid to an organ or tissue. Although it has been widely studied in the context of organ preservation and transplantation, it has also proven to be an invaluable tool in the development of novel models for translational pre-clinical research. Here, we review the literature reporting ex-vivo human liver perfusion experiments to further understand current perfusion techniques and protocols together with their applications. A computerised search was made of Ovid, MEDLINE, and Embase using the search words "ex-vivo liver or hepatic perfusion". All relevant studies in English describing experiments using ex-vivo perfusion of human livers between 2016 and 2021, inclusive, were included. Of 21 reviewed studies, 19 used ex-vivo human liver perfusion in the context of allogeneic liver transplantation. The quality and size of the studies varied considerably. Human liver perfusion was almost exclusively limited to whole organs and "split" livers, although one study did describe the successful perfusion of tissue sections following a partial hepatectomy. This review of recent literature involving ex-vivo human liver perfusion demonstrates that the technique is not limited to whole liver perfusion. Split-liver perfusion is extremely valuable allowing one lobe to act as a control and increasing the number available for research. This review also highlights the present lack of any reports of segmental liver perfusion. The discarded donor liver is a scarce resource, and the successful use of segmental perfusion has the potential to expand the available experimental models to facilitate pre-clinical experimentation.
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Affiliation(s)
- Trisha Kanani
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester NHS Trust, Leicester, GBR
| | - John Isherwood
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester NHS Trust, Leicester, GBR
| | - Eyad Issa
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester NHS Trust, Leicester, GBR
| | - Wen Y Chung
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester NHS Trust, Leicester, GBR
| | - Matteo Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, ITA
| | - Marco R Oggioni
- Department of Genetics and Genome Biology, University of Leicester, Leicester, GBR
| | - Giuseppe Garcea
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester NHS Trust, Leicester, GBR
| | - Ashley Dennison
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester NHS Trust, Leicester, GBR
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Bone marrow mesenchymal stem cells modified with heme oxygenase-1 alleviate rejection of donation after circulatory death liver transplantation by inhibiting dendritic cell maturation in rats. Int Immunopharmacol 2022; 107:108643. [DOI: 10.1016/j.intimp.2022.108643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/10/2022] [Accepted: 02/18/2022] [Indexed: 12/21/2022]
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Becker D, Eshmuminov D, Keller R, Mueller M, Bautista Borrego L, Hagedorn C, Duskabilova M, Tibbitt MW, Onder C, Clavien PA, Rudolf von Rohr P, Schuler MJ, Hefti M. Automated Insulin Delivery - Continuous Blood Glucose Control During Ex Situ Liver Perfusion. IEEE Trans Biomed Eng 2021; 68:1399-1408. [DOI: 10.1109/tbme.2020.3033663] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Javanbakht M, Mashayekhi A, Trevor M, Branagan-Harris M, Atkinson J. Cost-utility analysis of normothermic liver perfusion with the OrganOx metra compared to static cold storage in the United Kingdom. J Med Econ 2020; 23:1284-1292. [PMID: 32729749 DOI: 10.1080/13696998.2020.1804391] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Rising numbers of patients on the liver transplant waiting list has led to the utilization of organs from higher-risk donors that are more likely to be discarded and are prone to post-transplant complications. Storage and transportation of these livers at low temperatures can cause damage. OrganOx metra is a portable device intended to preserve and maintain the donated liver in normothermic conditions for up to 24 h prior to transplantation. OBJECTIVE To evaluate the cost-utility of normothermic machine perfusion with OrganOx metra in liver transplantation compared to the current practice of static cold storage (SCS). METHODS A de novo decision analytic model (a decision tree along with a Markov model), based on current treatment pathways, was developed to estimate the costs and outcomes. Results from a randomized clinical trial and national standard sources were used to inform the model. Costs were estimated from the National Health Service and Personal Social Services perspective. Deterministic and probabilistic sensitivity analyses (PSA) were conducted to explore uncertainty surrounding input parameters. RESULTS Over a lifetime time horizon, liver transplantation with OrganOx metra was more costly and more effective than the current practice of static cold storage. The total costs per patient were £37,370 vs £46,711, and the total effectiveness per patient was 9.09 QALYs vs 10.27 QALYs for SCS and OrganOx metra groups, respectively. The estimated ICER was £7,876 per each QALY gained. Results from the PSA showed that use of OrganOx metra has 99% probability of being cost-effective at a £20,000 willingness-to-pay threshold. OrganOx metra led to the utilization of 54 additional livers with patients experiencing lower rates of early allograft dysfunction and adverse events. CONCLUSIONS Use of OrganOx metra for the perfusion and transportation of livers prior to transplantation is a cost-effective strategy. KEY POINTS FOR DECISION MAKERS Introduction of OrganOx metra into NHS could increase the utilisation of donated livers with patients experiencing lower rates of early allograft dysfunction and adverse events, compared with current practice. Results of the economic analysis indicate that the OrganOx metra is highly likely to be cost-effective and result in improved patient outcomes.
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Affiliation(s)
- Mehdi Javanbakht
- Optimax Access UK Ltd, University of Southampton Science Park, Chilworth, UK
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Chilworth, UK
| | - Atefeh Mashayekhi
- Optimax Access UK Ltd, University of Southampton Science Park, Chilworth, UK
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Chilworth, UK
| | - Miranda Trevor
- School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Michael Branagan-Harris
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Chilworth, UK
| | - Jowan Atkinson
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Chilworth, UK
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Parente A, Osei-Bordom DC, Ronca V, Perera MTPR, Mirza D. Organ Restoration With Normothermic Machine Perfusion and Immune Reaction. Front Immunol 2020; 11:565616. [PMID: 33193335 PMCID: PMC7641637 DOI: 10.3389/fimmu.2020.565616] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022] Open
Abstract
Liver transplantation is the only recognized effective treatment for end-stage liver disease. However, organ shortages have become the main challenge for patients and physicians within the transplant community. Waiting list mortality remains an issue with around 10% of patients dying whilst waiting for an available organ. The post-transplantation period is also associated with an adverse complication rate for these specific cohorts of high-risk patients, particularly regarding patient and graft survival. Ischaemia reperfusion injury (IRI) has been highlighted as the mechanism of injury that increases parenchymal damage, which eventually lead to significant graft dysfunction and other poor outcome indicators. The consequences of IRI in clinical practice such as reperfusion syndrome, primary non-function of graft, allograft dysfunction, ischaemic biliary damage and early biliary complications can be life-threatening. IRI dictates the development of a significant inflammatory response that drives the pathway to eventual cell death. The main mechanisms of IRI are mitochondrial damage due to low oxygen tension within the hepatic micro-environment and severe adenosine triphosphate (ATP) depletion during the ischaemic period. After the restoration of normal blood flow, this damage is further enhanced by reoxygenation as the mitochondria respond to reperfusion by releasing reactive oxygen species (ROS), which in turn activate Kupffer cells within the hepatic micro-environment, leading to a pro-inflammatory response and eventual parenchymal cell apoptosis and associated tissue degradation. Machine perfusion (MP) is one emergent strategy considered to be one of the most important advances in organ preservation, restoration and transplantation. Indeed, MP has the potential to rescue frequently discarded organs and has been shown to limit the extent of IRI, leading to suppression of the deleterious pro-inflammatory response. This immunomodulation reduces the prevalence of allograft rejection, the use of immunosuppression therapy and minimizes post-transplant complications. This review aims to update the current knowledge of MP with a focus on normothermic machine liver perfusion (NMLP) and its potential role in immune response pathways.
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Affiliation(s)
- Alessandro Parente
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Daniel-Clement Osei-Bordom
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,National Institute for Health Research Birmingham Liver Biomedical Research Centre, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Vincenzo Ronca
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Division of Gastroenterology and Centre for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Darius Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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Yuzefovych Y, Valdivia E, Rong S, Hack F, Rother T, Schmitz J, Bräsen JH, Wedekind D, Moers C, Wenzel N, Gueler F, Blasczyk R, Figueiredo C. Genetic Engineering of the Kidney to Permanently Silence MHC Transcripts During ex vivo Organ Perfusion. Front Immunol 2020; 11:265. [PMID: 32140158 PMCID: PMC7042208 DOI: 10.3389/fimmu.2020.00265] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/31/2020] [Indexed: 12/29/2022] Open
Abstract
Organ gene therapy represents a promising tool to correct diseases or improve graft survival after transplantation. Polymorphic variation of the major histocompatibility complex (MHC) antigens remains a major obstacle to long-term graft survival after transplantation. Previously, we demonstrated that MHC-silenced cells are protected against allogeneic immune responses. We also showed the feasibility to silence MHC in the lung. Here, we aimed at the genetic engineering of the kidney toward permanent silencing of MHC antigens in a rat model. We constructed a sub-normothermic ex vivo perfusion system to deliver lentiviral vectors encoding shRNAs targeting β2-microglobulin and the class II transactivator to the kidney. In addition, the vector contained the sequence for a secreted nanoluciferase. After kidney transplantation (ktx), we detected bioluminescence in the plasma and urine of recipients of an engineered kidney during the 6 weeks of post-transplant monitoring, indicating a stable transgene expression. Remarkably, transcript levels of β2-microglobulin and the class II transactivator were decreased by 70% in kidneys expressing specific shRNAs. Kidney genetic modification did not cause additional cell death compared to control kidneys after machine perfusion. Nevertheless, cytokine secretion signatures were altered during perfusion with lentiviral vectors as revealed by an increase in the secretion of IL-10, MIP-1α, MIP-2, IP-10, and EGF and a decrease in the levels of IL-12, IL-17, MCP-1, and IFN-γ. Biodistribution assays indicate that the localization of the vector was restricted to the graft. This study shows the potential to generate immunologically invisible kidneys showing great promise to support graft survival after transplantation and may contribute to reduce the burden of immunosuppression.
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Affiliation(s)
- Yuliia Yuzefovych
- Hannover Medical School, Institute of Transfusion Medicine and Transplant Engineering, Hanover, Germany
| | - Emilio Valdivia
- Hannover Medical School, Institute of Transfusion Medicine and Transplant Engineering, Hanover, Germany
| | - Song Rong
- Department of Nephrology, Hannover Medical School, Hanover, Germany
| | - Franziska Hack
- Hannover Medical School, Institute of Transfusion Medicine and Transplant Engineering, Hanover, Germany
| | - Tamina Rother
- Hannover Medical School, Institute of Transfusion Medicine and Transplant Engineering, Hanover, Germany
| | - Jessica Schmitz
- Hannover Medical School, Institute for Pathology, Hanover, Germany
| | | | - Dirk Wedekind
- Hannover Medical School, Institute for Laboratory Animal Science, Hanover, Germany
| | - Cyril Moers
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Nadine Wenzel
- Hannover Medical School, Institute of Transfusion Medicine and Transplant Engineering, Hanover, Germany
| | - Faikah Gueler
- Department of Nephrology, Hannover Medical School, Hanover, Germany
| | - Rainer Blasczyk
- Hannover Medical School, Institute of Transfusion Medicine and Transplant Engineering, Hanover, Germany
| | - Constanca Figueiredo
- Hannover Medical School, Institute of Transfusion Medicine and Transplant Engineering, Hanover, Germany
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Said SA, Ordeñana CX, Rezaei M, Figueroa BA, Dasarathy S, Brunengraber H, Rampazzo A, Gharb BB. Ex-Vivo Normothermic Limb Perfusion With a Hemoglobin-Based Oxygen Carrier Perfusate. Mil Med 2020; 185:110-120. [PMID: 32074378 DOI: 10.1093/milmed/usz314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Ex-vivo normothermic limb perfusion (EVNLP) has been proven to preserve limb viability better than standard cold storage. Perfusates containing packed red blood cells (pRBC) improve outcomes when compared to acellular perfusates. Limitations of pRBC-based perfusion include limited availability, need for cross match, mechanical hemolysis, and activation of pro-inflammatory proteins. Hemoglobin-based oxygen carrier (HBOC)-201 (Hemopure) is a solution of polymerized bovine hemoglobin, characterized by low immunogenicity, no risk of hemolytic reaction, and enhanced convective and diffusive oxygen delivery. This is a preliminary study on the feasibility of EVNLP using HBOC-201 as an oxygen carrier. MATERIALS AND METHODS Three porcine forelimb perfusions were performed using an established EVNLP model and an HBOC-201-based perfusate. The perfusion circuit included a roller pump, oxygenator, heat exchanger, and reservoir. Electrolytes, limb temperature, weight, compartment pressure, nerve conduction, and perfusion indicated by indocyanine green angiography and infra-red thermography were monitored. Histological evaluation was performed with hematoxylin and eosin and electron microscopy. RESULTS Three limbs were perfused for 21.3 ± 2.1 hours. Muscle contractility was preserved for 10.6 ± 2.4 hours. Better preservation of the mitochondrial ultrastructure was evident at 12 hours in contrast to crystallization and destruction features in the cold-storage controls. CONCLUSIONS An HBOC-201-EVNLP produced outcomes similar to RBC-EVNLP with preservation of muscle contractility and mitochondrial structure.
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Affiliation(s)
- Sayf A Said
- Cleveland Clinic Foundation, Department of Plastic Surgery, 9500 Euclid Ave, A60, Cleveland, OH 44195
| | - Carlos X Ordeñana
- Cleveland Clinic Foundation, Department of Plastic Surgery, 9500 Euclid Ave, A60, Cleveland, OH 44195
| | - Majid Rezaei
- Cleveland Clinic Foundation, Department of Plastic Surgery, 9500 Euclid Ave, A60, Cleveland, OH 44195
| | - Brian A Figueroa
- Cleveland Clinic Foundation, Department of Plastic Surgery, 9500 Euclid Ave, A60, Cleveland, OH 44195
| | - Srinivasan Dasarathy
- Cleveland Clinic Foundation, Department of Gastroenterology, 9500 Euclid Ave, Cleveland, OH 44195
| | - Henri Brunengraber
- Department of Nutrition, School of Medicine, Case Western Reserve University, 2109 Adelbert Rd, BRB 901, Cleveland, OH 44106
| | - Antonio Rampazzo
- Cleveland Clinic Foundation, Department of Plastic Surgery, 9500 Euclid Ave, A60, Cleveland, OH 44195
| | - Bahar Bassiri Gharb
- Cleveland Clinic Foundation, Department of Plastic Surgery, 9500 Euclid Ave, A60, Cleveland, OH 44195
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Markin NW, Ringenberg KJ, Kassel CA, Walcutt CR, Chacon MM. 2018 Clinical Update in Liver Transplantation. J Cardiothorac Vasc Anesth 2019; 33:3239-3248. [DOI: 10.1053/j.jvca.2019.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/04/2019] [Indexed: 12/13/2022]
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