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Rodenas-Alesina E, Luk A, Gajasan J, Alhussaini A, Martel G, Serrick C, McRae K, Overgaard C, Cypel M, Singer L, Tikkanen J, Keshavjee S, Del Sorbo L. Implications of High Sensitivity Troponin Levels After Lung Transplantation. Transpl Int 2024; 37:12724. [PMID: 38665474 PMCID: PMC11043535 DOI: 10.3389/ti.2024.12724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024]
Abstract
Trends in high-sensitivity cardiac troponin I (hs-cTnI) after lung transplant (LT) and its clinical value are not well stablished. This study aimed to determine kinetics of hs-cTnI after LT, factors impacting hs-cTnI and clinical outcomes. LT recipients from 2015 to 2017 at Toronto General Hospital were included. Hs-cTnI levels were collected at 0-24 h, 24-48 h and 48-72 h after LT. The primary outcome was invasive mechanical ventilation (IMV) >3 days. 206 patients received a LT (median age 58, 35.4% women; 79.6% double LT). All patients but one fulfilled the criteria for postoperative myocardial infarction (median peak hs-cTnI = 4,820 ng/mL). Peak hs-cTnI correlated with right ventricular dysfunction, >1 red blood cell transfusions, bilateral LT, use of EVLP, kidney function at admission and time on CPB or VA-ECMO. IMV>3 days occurred in 91 (44.2%) patients, and peak hs-cTnI was higher in these patients (3,823 vs. 6,429 ng/mL, p < 0.001 after adjustment). Peak hs-cTnI was higher among patients with had atrial arrhythmias or died during admission. No patients underwent revascularization. In summary, peak hs-TnI is determined by recipient comorbidities and perioperative factors, and not by coronary artery disease. Hs-cTnI captures patients at higher risk for prolonged IMV, atrial arrhythmias and in-hospital death.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Adriana Luk
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - John Gajasan
- Interdepartmental Division of Critical Care Medicine, University Health Network, Toronto, ON, Canada
| | - Anhar Alhussaini
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Genevieve Martel
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Cyril Serrick
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Karen McRae
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | | | - Marcelo Cypel
- Division of Thoracic Surgery, Faculty of Surgery, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, ON, Canada
| | - Lianne Singer
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, ON, Canada
- Division of Respirology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, ON, Canada
- Division of Respirology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, Faculty of Surgery, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Center, University Health Network, Toronto, ON, Canada
- Division of Respirology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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2
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Ramjaun A, Hammond Mobilio M, Wright N, Masella M, Snyman A, Serrick C, Moulton CA. Beyond the Surgical Safety Checklist: Using Intraoperative Handoff to Facilitate Team Situation Awareness in the OR. Ann Surg 2023; 278:e1142-e1147. [PMID: 36912035 DOI: 10.1097/sla.0000000000005838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND The surgical safety checklist (SSC) has been credited with improving team situation awareness (SA) in the operating room. Although the SSC may support team SA at the outset of the operative case, intraoperative handoff provides an opportunity for either SA breakdown or, more preferably, SA reinforcement. High-functioning surgical teams demonstrate a high level of continued SA, whereas teams deficient in SA are more likely to be affected by surgical errors and adverse events. To date, no interprofessional intraoperative tools exist to support team SA beyond the SSC. METHODS This study was divided into 2 phases. The first used qualitative methods to (1) characterize intraoperative handoff processes across surgery, nursing, anesthesia, and perfusion, and (2) identify cultural factors that shaped handoff practices. Data for phase one were collected over 38 observation days and 41 brief interviews. Phase 2, informed by phase 1, used a modified Delphi process to create a tool for use during intraoperative handoff. Data were analyzed iteratively. RESULTS Handoff practices were not standardized and rarely involved the entire team. In addition we uncovered cultural factors-specifically assumptions held by participants-that hindered team communication during handoff. Assumptions included: (1) team members are interchangeable, (2) trained individuals are able to determine when it is appropriate to handoff without consulting the OR team. Despite claims of improved teamwork resulting from the SSC, many participants held a fragmented view of the OR team, resulting in communication challenges during handoff. Findings from both phases of our study informed the development of multidisciplinary intraoperative handoff tools to facilitate shared team situation awareness and a shared mental model. CONCLUSIONS Intraoperative handoff occurs frequently, and offers the opportunity for either renewed or fractured team SA beyond the SSC.
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Affiliation(s)
| | | | - Nicole Wright
- The Wilson Centre, Toronto, ON, Canada
- Toronto General Hospital, Toronto, ON, Canada
| | | | - Adam Snyman
- Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | | | - Carol-Anne Moulton
- The Wilson Centre, Toronto, ON, Canada
- Toronto General Hospital, Toronto, ON, Canada
- Department of Surgery, University Health Network, Toronto, ON, Canada
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3
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Beairsto B, Serrick C, Fernandez A, Lafreniere-Roula M, Badiwala M, Karkouti K, Rao V. Platelet preservation in cardiac surgery using minimally invasive extracorporeal circulation versus optimized cardiopulmonary bypass. Perfusion 2023; 38:1705-1713. [PMID: 36172835 PMCID: PMC10612373 DOI: 10.1177/02676591221130173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Minimally invasive extracorporeal circulation (MiECC) is employed as a strategy to attenuate the physiologic disturbance caused by cardiopulmonary bypass. The aim of this study was to compare the coagulation profile of MiECC to an optimized conventional extracorporeal circuit (OpECC) with regards to platelet function, rotational thromboelastometry and blood product usage. METHODS A retrospective analysis of coronary artery bypass grafting operations using either MiECC or OpECC was performed at a single institution. RESULTS A total of 112 patients were included, with 61 receiving MiECC and 51 OpECC patients. OpECC patients had a significantly larger BSA (1.95+/- 0.22m2 vs 1.88 +/- 0.18m2, p = 0.034), than those who received MiECC. No difference between groups was observed regarding red blood cell, plasma, and platelet transfusions. Functional platelet count during the warming phase of cardiopulmonary bypass was found to be higher in the MiECC group ((136 (102-171) x109/L vs 109 (94-136) x109/L), p = 0.027), as were functional platelets as a percent of total platelet count ((86 (77-91)% vs 76 (63-82)%), p = 0.003). There were no significant differences between other outcomes such as operative mortality, incidence of stroke, and intensive care unit length of stay. CONCLUSION While we did not see a difference in blood transfusions, MiECC resulted in a statistically significant advantage over OpECC with regards to preservation of functional platelets.
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Affiliation(s)
- Brian Beairsto
- Department of Perfusion, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Cyril Serrick
- Department of Perfusion, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Amanda Fernandez
- Department of Perfusion, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | | | - Mitesh Badiwala
- Department of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesiology, University Health Network, Toronto, ON, Canada
| | - Vivek Rao
- Department of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
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Anastasiadis K, Antonitsis P, Murkin J, Serrick C, Gunaydin S, El-Essawi A, Bennett M, Erdoes G, Liebold A, Punjabi P, Theodoropoulos KC, Kiaii B, Wahba A, de Somer F, Bauer A, Kadner A, van Boven W, Argiriadou H, Deliopoulos A, Baker RΑ, Breitenbach I, Ince C, Starinieri P, Jenni H, Popov V, Moorjani N, Moscarelli M, Di Eusanio M, Cale A, Shapira O, Baufreton C, Condello I, Merkle F, Stehouwer M, Schmid C, Ranucci M, Angelini G, Carrel T. 2021 MiECTiS focused update on the 2016 position paper for the use of minimal invasive extracorporeal circulation in cardiac surgery. Perfusion 2023; 38:1360-1383. [PMID: 35961654 DOI: 10.1177/02676591221119002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related technologies. The current expert consensus document offers an update in areas for which new evidence has emerged. In the light of published literature, modular minimal invasive extracorporeal circulation (MiECC) has been established as a safe and effective perfusion technique that increases biocompatibility and ultimately ensures perfusion safety in all adult cardiac surgical procedures, including re-operations, aortic arch and emergency surgery. Moreover, it was recognized that incorporation of MiECC strategies advances minimal invasive cardiac surgery (MICS) by combining reduced surgical trauma with minimal physiologic derangements. Minimal Invasive Extracorporeal Technologies International Society considers MiECC as a physiologically-based multidisciplinary strategy for performing cardiac surgery that is associated with significant evidence-based clinical benefit that has accrued over the years. Widespread adoption of this technology is thus strongly advocated to obtain additional healthcare benefit while advancing patient care.
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Affiliation(s)
- Kyriakos Anastasiadis
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - Polychronis Antonitsis
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - John Murkin
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Cyril Serrick
- Department of Perfusion, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Aschraf El-Essawi
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Mark Bennett
- Department of Anesthesia, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Andreas Liebold
- Department of Cardio-thoracic Surgery, University Hospital Ulm, Ulm, Germany
| | - Prakash Punjabi
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Bob Kiaii
- Division of Cardiothoracic Surgery, UC Davis Health, Sacramento, CA, USA
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway and Department of Circulation and Medical Imaging, University of Science and Technology, Trondheim, Norway
| | - Filip de Somer
- Department of Cardiac Surgery, University Hospital Ghent, Ghent, Belgium
| | - Adrian Bauer
- Department of Cardiovascular Perfusion, MediClin Heart Center, Coswig, Saxony-Anhalt, Germany
| | - Alexander Kadner
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Switzerland
| | | | - Helena Argiriadou
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - Apostolos Deliopoulos
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - Robert Α Baker
- Cardiothoracic Surgery Quality and Outcomes, and Perfusion, Flinders Medical Centre and Flinders University, Adelaide, South Australia, Australia
| | - Ingo Breitenbach
- Department of Thoracic and Cardiovascular Surgery, Braunschweig Clinic, Braunschweig, Germany
| | - Can Ince
- Department of Intensive Care, Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Hansjoerg Jenni
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Switzerland
| | - Vadim Popov
- Department of Cardio-Vascular Surgery, Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, University of Cambridge, Cambridge, UK
| | - Marco Moscarelli
- Cardiac Surgery, Anthea Hospital Gvm Care & Research, Bari, Italy
| | - Marco Di Eusanio
- Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Alex Cale
- Department of Cardiac Surgery, Hull and East Yorkshire Hospitals NHS Trust, UK
| | - Oz Shapira
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Ignazio Condello
- Cardiac Surgery, Anthea Hospital Gvm Care & Research, Bari, Italy
| | - Frank Merkle
- Academy for Perfusion, German Heart Institute Berlin, Berlin, Germany
| | - Marco Stehouwer
- Department of Clinical Perfusion, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Gianni Angelini
- Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zürich, Zurich, Switzerland
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5
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Rodenas-Alesina E, Luk A, Gajasan J, Alhussaini A, Overgaard C, Martel G, Serrick C, McRae K, Cypel M, Singer L, Tikkanen J, Keshavjee S, Sorbo LD. Prognostic Significance of Serial Troponin Measurement after Lung Transplantation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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6
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Li H, Bartoszko J, Serrick C, Rao V, Karkouti K. Titrated versus conventional anticoagulation management for thrombin generation in cardiac surgery: a randomized controlled trial. Can J Anaesth 2022; 69:1117-1128. [PMID: 35799088 DOI: 10.1007/s12630-022-02278-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Optimal heparin titration during cardiopulmonary bypass (CPB) may reduce coagulation system activation and preserve hemostatic function post-CPB. Our objective was to assess if the Heparin Management System (HMS) Plus improves heparin titration, thereby leading to higher thrombin generation post-CPB compared with activated clotting time (ACT)-guided management. METHODS We conducted a randomized controlled trial of 100 patients undergoing cardiac surgery with CPB at a single center. A total of 50 patients were randomized to conventional ACT-guided management, and 50 to the HMS Plus system. The primary outcome was change in thrombin generation post-CPB compared with baseline, as assessed by calibrated automated thrombography. Secondary outcomes included intraoperative blood loss, chest drain output up to 72 hr, and transfusions. In an exploratory analysis, we compared the quintile of patients with the highest average heparin concentration on CPB (≥ 4.0 mg⋅kg-1) with the rest of the cohort. RESULTS A total of 100 patients were included in an intent-to-treat analysis. We observed no difference in post-CPB thrombin generation or secondary outcomes. However, patients in the HMS Plus group had higher average heparin concentrations while on CPB than patients in the conventional management group did (mean difference, -0.21; 95% confidence interval, -0.42 to -0.01). The quintile of patients with the highest average heparin concentration (4.0 mg⋅kg-1) had higher thrombin generation post-CPB than the rest of the cohort did. CONCLUSIONS The HMS Plus system did not show significant benefits in thrombin generation, bleeding outcomes, or transfusion in patients undergoing cardiac surgery with CPB. Higher average heparin concentrations on CPB were associated with higher post-CPB thrombin generation. STUDY REGISTRATION www. CLINICALTRIALS gov (NCT03347201); first submitted 12 October 2017.
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Affiliation(s)
- Han Li
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Cyril Serrick
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Vivek Rao
- Cardiovascular Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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7
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Murkin JM, Serrick C, Antonitsis P, Anastasiadis K, Punjabi PP. Virtual 4th MiECT Symposium: Innovation and Future. Perfusion 2021; 36:654-655. [PMID: 34528848 DOI: 10.1177/02676591211042712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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8
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Jansa L, Fischer C, Serrick C, Rao V. PROTAMINE TEST DOSE: IMPACT ON ACTIVATED CLOTTING TIME AND CIRCUIT INTEGRITY. Ann Thorac Surg 2021; 113:506-510. [PMID: 33961816 DOI: 10.1016/j.athoracsur.2021.04.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 04/11/2021] [Accepted: 04/27/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recurrent observation of clot in the cardiopulmonary bypass circuit following the administration of a Protamine Test Dose (PTD) prompted concern into the effects of PTDs on patient activated clotting times (ACT). METHODS Data was prospectively collected on 120 cardiopulmonary bypass patients undergoing a variety of cardiac surgeries from July to October, 2018. ACTs were documented prior to cardiopulmonary bypass termination, post PTD, and post protamine full dose. Statistical analysis was completed using a paired t-test. RESULTS The average PTD was calculated to be 36+21 mg or 11+7% of the full protamine dose of 367+153 mg. This "test" dose ranged from 1% to 67% of full dose depending upon the anesthetist. Post PTD ACTs were widely variable. On average, there was a 40+25% drop from last ACT on cardiopulmonary bypass (650+155 sec) to the ACT post PTD (376+153 sec) p<0.0001. In fact, 81+5% of the patient's post PTD ACTs fell below our institutional ACT standard of 480 seconds for safe cardiopulmonary bypass initiation. CONCLUSIONS Regardless of the protamine test dosage, there is no reliable way to predict how a patient's ACT will respond to a protamine test dose. Clot formation and circuit integrity is at risk when pump suction devices are continuously in use during PTD administration. Therefore, we strongly recommend that the direct recovery of mediastinal shed blood into the pump circuit be discontinued before any amount of protamine is administered to the patient.
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Affiliation(s)
- Lauren Jansa
- Departments of Perfusion and Anesthesia and Pain Management, and the Division of Cardiovascular Surgery. Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Courtney Fischer
- Departments of Perfusion and Anesthesia and Pain Management, and the Division of Cardiovascular Surgery. Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Cyril Serrick
- Departments of Perfusion and Anesthesia and Pain Management, and the Division of Cardiovascular Surgery. Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Vivek Rao
- Departments of Perfusion and Anesthesia and Pain Management, and the Division of Cardiovascular Surgery. Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
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9
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Li H, Serrick C, Rao V, Yip PM. A comparative analysis of four activated clotting time measurement devices in cardiac surgery with cardiopulmonary bypass. Perfusion 2020; 36:610-619. [DOI: 10.1177/0267659120949351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: In cardiac surgery on cardiopulmonary bypass (CPB), heparin anticoagulation is monitored by point-of-care measurement of activated clotting time (ACT). The objective of this study was to compare four ACT systems in cardiac surgery in terms of their reproducibility, agreement and potential clinical impact at relevant medical decision points. Methods: The study included 40 cardiac surgery patients. Samples were taken at five time points before (T1), after heparinization for CPB (T2, T3, T4), and after heparin reversal (T5). The reproducibility, correlation, and differences in ACT values were assessed with two devices from each of the four ACT systems: Instrumentation Laboratory Hemochron Elite (Hmch), Medtronic HMS Plus (HMS), Abbott i-STAT, and Helena Abrazo. Subrange analyses were performed for low ACT values (results from T1, T5) and high ACT values (results from T2, T3, T4). Results: Within-system analysis showed strong linear correlation between paired measurements (R = 0.968-0.993). However, Hmch showed poorer reproducibility with highest proportion of values that exceed a difference of 10% and highest overall standard error of 74 seconds across the measurement range compared to that of the others (range 39-47 seconds, respectively). For inter-system comparison, using Hmch as reference, ACTs were strongly correlated as follows: HMS (R = 0.938), i-STAT (R = 0.911), and Abrazo (R = 0.911). Agreement analysis in the high ACT range showed HMS tended to have higher ACT values with +11% bias over Hmch, whereas i-STAT (–8% bias) and Abrazo (–13% bias) tended to underestimate. Post-protamine ACT results were dependent on device type where Hmch yielded highest post-protamine ACT (+13% higher than baseline) compared to –16% for HMS, –10% for iSTAT and 0% for Abrazo. Conclusions: Each device had individual reproducibility and biases, which may impact peri-operative heparin management. Careful validation must be undertaken when adopting a different method as decision limits would be affected. Clinicians should also be cautious using ACT as the only indicator for full heparin reversal.
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Affiliation(s)
- Han Li
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Cyril Serrick
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Vivek Rao
- Cardiovascular Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Paul M Yip
- Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, ON, Canada
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10
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Ribeiro RVP, Alvarez JS, Yu F, Adamson MB, Fukunaga N, Serrick C, Bissoondath V, Meineri M, Badiwala MV, Rao V. A Pre-Clinical Porcine Model of Orthotopic Heart Transplantation. J Vis Exp 2019. [PMID: 31081813 DOI: 10.3791/59197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Fifty-years following the first successful report, cardiac transplantation remains the gold-standard treatment for eligible patients with advanced heart failure. Multiple small-animal models of heart transplantation have been used to study the acute and long-term effects of novel therapies. However, few are tested and demonstrated success in clinical trials. It is of critical importance to evaluate new therapies in a clinically relevant large-animal model for efficient and reliable translation of basic studies' findings. Here, we describe a pre-clinical large-animal (porcine) model of orthotopic heart transplantation that has been firmly established and previously used to investigate novel cardioprotective strategies. This procedure focuses on acute ischemia-reperfusion injury and is a reliable method to investigate novel interventions which have been tested and validated in smaller experimental models, such as the murine model. We demonstrate its usefulness in assessing cardiac performance during the early post-transplantation period and other potential possibilities enabled by the model.
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Affiliation(s)
- Roberto V P Ribeiro
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network; Institute of Medical Science, University of Toronto;
| | - Juglans S Alvarez
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network
| | - Frank Yu
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network
| | - Mitchell B Adamson
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network; Institute of Medical Science, University of Toronto
| | - Naoto Fukunaga
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network
| | - Cyril Serrick
- Perfusion and Anesthesia Services, Toronto General Hospital, University Health Network
| | - Ved Bissoondath
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network
| | - Massimiliano Meineri
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network; Department of Anesthesia, University of Toronto
| | - Mitesh V Badiwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network; Department of Surgery, Faculty of Medicine, University of Toronto
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network; Institute of Medical Science, University of Toronto; Department of Surgery, Faculty of Medicine, University of Toronto
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Vanin Pinto Ribeiro R, Alvarez J, Yu F, Adamson M, Paradiso E, Ruggeri G, Fukunaga N, Bissoondath V, Serrick C, Meineri M, Rao V, Badiwala M. IS COLD STORAGE POSSIBLE IN HEARTS DONATED AFTER CIRCULATORY DEATH? A PRE-CLINICAL STUDY. Can J Cardiol 2018. [DOI: 10.1016/j.cjca.2018.07.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Selzner M, Goldaracena N, Echeverri J, Kaths JM, Linares I, Selzner N, Serrick C, Marquez M, Sapisochin G, Renner EL, Bhat M, McGilvray ID, Lilly L, Greig PD, Tsien C, Cattral MS, Ghanekar A, Grant DR. Normothermic ex vivo liver perfusion using steen solution as perfusate for human liver transplantation: First North American results. Liver Transpl 2016; 22:1501-1508. [PMID: 27339754 DOI: 10.1002/lt.24499] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/08/2016] [Accepted: 05/23/2016] [Indexed: 12/12/2022]
Abstract
The European trial investigating normothermic ex vivo liver perfusion (NEVLP) as a preservation technique for liver transplantation (LT) uses gelofusine, a non-US Food and Drug Administration-approved, bovine-derived, gelatin-based perfusion solution. We report a safety and feasibility clinical NEVLP trial with human albumin-based Steen solution. Transplant outcomes of 10 human liver grafts that were perfused on the Metra device at 37 °C with Steen solution, plus 3 units of erythrocytes were compared with a matched historical control group of 30 grafts using cold storage (CS) as the preservation technique. Ten liver grafts were perfused for 480 minutes (340-580 minutes). All livers cleared lactate (final lactate 1.46 mmol/L; 0.56-1.74 mmol/L) and produced bile (61 mL; 14-146 mL) during perfusion. No technical problems occurred during perfusion, and all NEVLP-preserved grafts functioned well after LT. NEVLP versus CS had lower aspartate aminotransferase and alanine aminotransferase values on postoperative days 1-3 without reaching significance. No difference in postoperative graft function between NEVLP and CS grafts was detected as measured by day 7 international normalized ratio (1.1 [1-1.56] versus 1.1 [1-1.3]; P = 0.5) and bilirubin (1.5; 1-7.7 mg/dL versus 2.78; 0.4-15 mg/dL; P = 0.5). No difference was found in the duration of intensive care unit stay (median, 1 versus 2 days; range, 0-8 versus 0-23 days; P = 0.5) and posttransplant hospital stay (median, 11 versus 13 days; range, 8-17 versus 7-89 days; P = 0.23). Major complications (Dindo-Clavien ≥ 3b) occurred in 1 patient in the NEVLP group (10%) compared with 7 (23%) patients in the CS group (P = 0.5). No graft loss or patient death was observed in either group. Liver preservation with normothermic ex vivo perfusion with the Metra device using Steen solution is safe and results in comparable outcomes to CS after LT. Using US Food and Drug Administration-approved Steen solution will avoid a potential regulatory barrier in North America. Liver Transplantation 22 1501-1508 2016 AASLD.
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Affiliation(s)
- Markus Selzner
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Juan Echeverri
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Johan M Kaths
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ivan Linares
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Nazia Selzner
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Cyril Serrick
- Perfusion Services, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Max Marquez
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eberhard L Renner
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ian D McGilvray
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Leslie Lilly
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Paul D Greig
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Cynthia Tsien
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mark S Cattral
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - David R Grant
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
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Bell J, Yamamoto Y, Jenni H, Mclean L, Chiarella G, El-Essawi A, Glendza D, Antonitsis P, Boer C, Durandy Y, Erdoes G, Murkin J, Starinieri P, Starinieri P, Spriel A, Bauer A, McLean L, Medlam W, Bennett R, Bennett R, Turner E, Wallhead A, Winkler B, Erdös G, Eberle B, Carrel T, Medlam W, Bell J, Bennett R, Bennett R, Wallhead A, Turner E, Benvenuto D, Ciano M, Losito G, Mazzei V, Breitenbach I, Haupt B, Morjan M, Brower R, Harringer W, Dedieu F, Crispin V, Aunac S, Guennaoui T, Van Ruyssevelt P, Kostarellou G, Argiriadou H, Kleontas A, Deliopoulos A, Grosomanidis V, Anastasiadis K, Stolze A, Vonk A, Burtman D, Basciani R, Kröninger F, Gygax E, Jenni H, Reineke D, Stucki M, Hagenbuch N, Carrel T, Eberle B, Turkstra T, Mayer R, Robic B, Wen W, Yilmaz A, Robic B, Wen W, Yilmaz A, Nguyen-Vu M, Serrick C, Hausmann H, Eberle T, Troitzsch D, Johansen P, Nygaard H, Hasenkam J. 2nd International Symposium on Minimal Invasive Extracorporeal Technologies Athens, Greece, 9-11 June 2016001SAFETY IN THE EVOLVING MINIATURIZED EXTRACORPOREAL SYSTEM002THE CHALLENGE OF CLOSED CIRCUIT SYSTEM FOR ALL CARDIOPULMONARY BYPASS CASES003THE USE OF A MINIMAL INVASIVE EXTRACORPOREAL CIRCUIT FOR REWARMING PATIENTS FROM ACCIDENTAL HYPOTHERMIA: A PROSPECTIVE STUDY004WHAT ARE THE LIMITATIONS OF MINIATURIZED ADULT CARDIOPULMONARY BYPASS? OUR FINDINGS005AORTIC VALVE SURGERY AND CORONARY BYPASS SURGERY IN DIALYZED PATIENTS. MAY MINIMAL EXTRACORPOREAL CIRCULATION BE HELPFUL IN GETTING BETTER RESULTS?006IMPACT OF MINIMAL EXTRACORPOREAL CIRCULATION IN OCTOGENARIANS UNDERGOING CORONARY ARTERY BYPASS GRAFTING. HAVE WE BEEN LOOKING IN THE WRONG DIRECTION?007CORONARY ARTERY BYPASS GRAFTING ON BEATING HEART, ON CARDIOPULMONARY BYPASS OR ON MINIMAL EXTRACORPOREAL CIRCULATION008MINIMAL INVASIVE EXTRACORPOREAL CIRCULATION IMPROVES QUALITY OF LIFE AFTER CORONARY ARTERY BYPASS GRAFTING009MINIMAL INVASIVE DETERMINATIONS OF OXYGEN DELIVERY (DO 2) AND CONSUMPTION (VO 2) IN CARDIAC SURGERY010CONTINUOUS MONITORING OF PERFUSION INDEX AND PULSE OXIMETRY DURING WARM PULSATILE PERFUSION IN PAEDIATRICS011CEREBRAL MICROEMBOLIZATION IN PATIENTS UNDERGOING SURGICAL AORTIC VALVE REPLACEMENT ON MINIMAL INVASIVE OR CONVENTIONAL EXTRACORPOREAL CIRCULATION012ASSESSMENT OF AUTOMATED SOMATOSENSORY EVOKED POTENTIALS FOR DETECTION OF INTRAOPERATIVE POSITIONAL NEUROPRAXIA IN CARDIAC SURGERY013MINIMAL INVASIVE EXTRACORPOREAL CIRCULATION IN MINIMALLY INVASIVE AORTIC VALVE SURGERY014MINIMAL INVASIVE EXTRACORPOREAL CIRCULATION IN ENDOSCOPIC MITRAL VALVE SURGERY015AIR HANDLING CAPABILITY OF A CONVENTIONAL CARDIOPULMONARY BYPASS VERSUS MINIMIZED EXTRACORPOREAL CIRCUIT USING THE FUSION OXYGENATOR016DOES MINIMALLY INVASIVE EXTRACORPOREAL CIRCULATION AND CELL SALVAGE REDUCE INFLAMMATION AFTER CORONARY ARTERY BYPASS GRAFTING SURGERY? Interact Cardiovasc Thorac Surg 2016. [DOI: 10.1093/icvts/ivw269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Anastasiadis K, Murkin J, Antonitsis P, Bauer A, Ranucci M, Gygax E, Schaarschmidt J, Fromes Y, Philipp A, Eberle B, Punjabi P, Argiriadou H, Kadner A, Jenni H, Albrecht G, van Boven W, Liebold A, de Somer F, Hausmann H, Deliopoulos A, El-Essawi A, Mazzei V, Biancari F, Fernandez A, Weerwind P, Puehler T, Serrick C, Waanders F, Gunaydin S, Ohri S, Gummert J, Angelini G, Falk V, Carrel T. Use of minimal invasive extracorporeal circulation in cardiac surgery: principles, definitions and potential benefits. A position paper from the Minimal invasive Extra-Corporeal Technologies international Society (MiECTiS). Interact Cardiovasc Thorac Surg 2016; 22:647-62. [PMID: 26819269 DOI: 10.1093/icvts/ivv380] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/25/2015] [Indexed: 12/11/2022] Open
Abstract
Minimal invasive extracorporeal circulation (MiECC) systems have initiated important efforts within science and technology to further improve the biocompatibility of cardiopulmonary bypass components to minimize the adverse effects and improve end-organ protection. The Minimal invasive Extra-Corporeal Technologies international Society was founded to create an international forum for the exchange of ideas on clinical application and research of minimal invasive extracorporeal circulation technology. The present work is a consensus document developed to standardize the terminology and the definition of minimal invasive extracorporeal circulation technology as well as to provide recommendations for the clinical practice. The goal of this manuscript is to promote the use of MiECC systems into clinical practice as a multidisciplinary strategy involving cardiac surgeons, anaesthesiologists and perfusionists.
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Affiliation(s)
| | - John Murkin
- Department of Anesthesiology and Perioperative Medicine, University of Western Ontario, London, Canada
| | | | - Adrian Bauer
- Department of Cardiothoracic Surgery, MediClin Heart Centre Coswig, Coswig, Germany
| | - Marco Ranucci
- Department of Anaesthesia and Intensive Care, Policlinico S. Donato, Milan, Italy
| | - Erich Gygax
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
| | - Jan Schaarschmidt
- Department of Cardiothoracic Surgery, MediClin Heart Centre Coswig, Coswig, Germany
| | - Yves Fromes
- University Pierre and Marie Curie (Paris 06), Paris, France
| | | | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy, University of Bern, Bern, Switzerland
| | - Prakash Punjabi
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
| | - Helena Argiriadou
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Alexander Kadner
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
| | - Hansjoerg Jenni
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
| | - Guenter Albrecht
- Department of Cardiothoracic and Vascular Surgery, Ulm University, Ulm, Germany
| | - Wim van Boven
- Department of Cardiothoracic Surgery, Amsterdam Medical Center, Amsterdam, Netherlands
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, Ulm University, Ulm, Germany
| | | | - Harald Hausmann
- Department of Cardiothoracic Surgery, MediClin Heart Centre Coswig, Coswig, Germany
| | | | - Aschraf El-Essawi
- Department of Thoracic and Cardiovascular Surgery, Braunschweig, Germany
| | - Valerio Mazzei
- Department of Adult Cardiac Surgery, Mater Dei Hospital, Bari, Italy
| | - Fausto Biancari
- Department of Cardiac Surgery, Oulu University Hospital, Oulu, Finland
| | - Adam Fernandez
- Department of Surgery, Sidra Medical & Research Centre, Doha, Qatar
| | - Patrick Weerwind
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Thomas Puehler
- Department of Thoracic and Cardiovascular Surgery, University Hospital of the Rhine University Bochum, Bad Oeynhausen, Germany
| | | | | | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Medline Hospitals, Adana, Turkey
| | - Sunil Ohri
- Department of Cardiothoracic Surgery, Wessex Cardiac Centre, University Hospital Southampton, Hampshire, UK
| | - Jan Gummert
- Department of Thoracic and Cardiovascular Surgery, University Hospital of the Rhine University Bochum, Bad Oeynhausen, Germany
| | - Gianni Angelini
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK
| | - Volkmar Falk
- Department of Cardiothoracic Surgery, German Heart Centre, Berlin, Germany
| | - Thierry Carrel
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
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Goldraich L, Foroutan F, Ross H, Serrick C, McDonald M, Billia P, Delgado D, Yau T, Cusimano R, Rao V. Are Continuous-Flow LVADs Associated With Vasoplegia at the Time of Heart Transplant? J Heart Lung Transplant 2015. [DOI: 10.1016/j.healun.2015.01.580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Cherryman F, Cunningham V, Aubin M, Holmes J, Serrick C, Tsirigotis D. SIMULATED TEAM-BASED CPB EMERGENCY PREPAREDNESS TRAINING. Can J Cardiol 2014. [DOI: 10.1016/j.cjca.2014.07.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Scholz M, Serrick C, Noel D, Singh O, Melo A. A prospective comparison of the platelet sequestration ability of three autotransfusion devices. J Extra Corpor Technol 2005; 37:286-9. [PMID: 16350382 PMCID: PMC4680787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Although current autotransfusion devices have platelet sequestration capabilities, each has a unique technology to achieve the final platelet product. The purpose of this study was to assess the quality and quantity of platelets sequestered by three different autotransfusion devices. The three commercially available autotransfusion devices evaluated were Fresenius C.A.T.S (closed spiral chamber), Cobe BRAT 2 (Baylor bowl), and Haemonetic Cell Saver 5 (Latham bowl). Platelet sequestration was preformed in the automatic mode following the manufacturer's recommended sequestration protocols. The total number of platelets sequestered, percent recovery, and percent platelet function were assessed. Each device behaved similarly. There was a 2- to 3-fold increase in platelet count compared with baseline with only approximately 50-60% recovery, whereas there was approximately a 10% decrease in platelet function after processing compared with baseline. No statistical difference was noted in platelet function between the respective machines. However, there was a significant loss of platelet function observed with the actual process regardless of autotransfusion device used.
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Affiliation(s)
- Mary Scholz
- Trillium Health Centre, Perfusion Dept., Mississauga Site 100, Queensway West Mississauga, ON L5B 1B8 Canada.
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Lee AG, Wagner FM, Chen MF, Serrick C, Giaid A, Shennib H. A novel charcoal-induced model of obliterative bronchiolitis-like lesions: implications of chronic nonspecific airway inflammation in the development of posttransplantation obliterative bronchiolitis. J Thorac Cardiovasc Surg 1998; 115:822-7. [PMID: 9576217 DOI: 10.1016/s0022-5223(98)70362-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES In this study, we describe the development of a nonallogeneic animal model of obliterative bronchiolitis-like lesions. Furthermore, we examined whether chronic rejection alone can lead to the development of obliterative bronchiolitis or whether additional nonspecific airway inflammation is required. METHODS Part I: Rats were intratracheally injected with 0.2 ml of activated charcoal or sorbitol solution (carrier for charcoal control). Animals were put to death beginning at 2 weeks up to 20 weeks. Part II: Animals were divided into three groups: group I, underimmunosuppressed Brown Norway to Lewis lung allografts; group II, charcoal-treated underimmunosuppressed allografts; and group III, charcoal-treated rats. Animals were put to death at 3 months after transplantation. RESULTS Part I: In charcoal-laden bronchioles, subacute nonspecific airway inflammation was detected at 2 weeks. Slow, subclinical fibroproliferation ensued during the following weeks. Obliterative bronchiolitis-like lesions were observed in 80% of charcoal-treated animals at 12 weeks. Part II: Allografts developed extensive vascular lesions consistent with acute and chronic vascular rejection. Obliterative bronchiolitis-like lesions were scarcely detected. Charcoal-treated allografts demonstrated evidence of diffuse and severe obliterative bronchiolitis-like lesions. CONCLUSIONS Transtracheal injection of activated charcoal into native lungs results in slowly progressive airway injury and inflammation leading to obliterative airway lesions. Inadequate immunosuppression primarily results in chronic vascular rejection but not obliterative bronchiolitis. Underimmunosuppressed allografts subjected to nonspecific airway inflammation develop obliterative airway lesions that are more prominent than in native lungs. This suggests that a cofactor to chronic rejection is likely necessary for the development of lung transplant obliterative bronchiolitis.
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Affiliation(s)
- A G Lee
- The Montreal Lung Transplant Program, Quebec, Canada
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Lee AG, Wagner FM, Giaid A, Chen MF, Hamid Q, Serrick C, Shennib H. Immunohistochemical characterization of inflammatory and proliferative events during chronic rejection in rat lung allografts. Transplantation 1997; 64:465-71. [PMID: 9275114 DOI: 10.1097/00007890-199708150-00016] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Chronic rejection is assumed to be the principle cause of airway injury leading to obliterative bronchiolitis (OB) after lung transplantation (Tx). To better understand the contribution of chronic rejection in the development of OB in allografted lungs, we examined the histopathological changes and cytokine expression in inadequately immunosuppressed rat lung allografts. METHODS Three groups of rats were studied: group I, control nontransplanted Lewis (Lew) rats (n=5); group II, syngeneic Lew-to-Lew isografts (n=25); and group III, Brown Norway-to-Lew allografts (n=25). Groups II and III received two single doses of cyclosporine on postoperative days 2-3. Transplanted animals were killed (n=5) at monthly intervals from 2 months to 6 months after Tx. Resected lungs were stained with hematoxylin and eosin, Masson's trichrome, and Van Gieson's elastin, and immunostained with antisera to interleukin (IL)-1beta, IL-8, and basic fibroblast growth factor (bFGF). The intensity of immunostaining was graded from 0 to 4 (0=no staining, 4=strong staining). RESULTS In groups I and II, normal airways and vessels were observed. Minimal intensity and distribution of immunostaining for all markers were detected in groups I and II. Group III allografts demonstrated acute grade II-III vascular rejection with mild bronchiolar injury and inflammation at 2 months after Tx. At 6 months after Tx, all allografts demonstrated severe and diffuse chronic vascular rejection. Late airway changes consistent with OB were detected in four of five allografts, however, these lesions were expressed infrequently. Immunohistochemical findings revealed moderate to strong expression for IL-8 and bFGF over the airway epithelium, acute and chronic inflammatory cells, and fibroblasts in allografts at 2 months after Tx. Despite focal development of OB at 6 months, intensity and distribution of immunostaining significantly decreased for all three cytokine markers. CONCLUSIONS Inadequate immunosuppression of rat lung allografts leads primarily to chronic vascular rejection but fails to induce severe and diffuse development of OB. In this animal model, cytokines IL-1beta, IL-8, and bFGF are likely to play an important role in the early inflammatory phase but not during the late proliferative events of chronic rejection.
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Affiliation(s)
- A G Lee
- The Montreal Lung Transplant Laboratories, The Montreal General Hospital, Quebec, Canada
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Abstract
BACKGROUND Previously it was found that ischemia-reperfusion injury in a left lung autotransplantation model could be a minor inducer of major histocompatibility complex (MHC) class II antigen expression. Thus, we hypothesized that prolonged ischemic times may result in increased expression of MHC class II antigens and predispose the lungs to the development of acute rejection early after transplantation. METHODS Twenty conditioned dogs underwent single left lung allotransplantation. Donor lungs were subjected to 4 or 24 hours (n = 10 each) of cold ischemia. Open lung biopsies, bronchoalveolar lavage fluid, and blood samples were taken preoperatively and at various intervals up to 1 week after transplantation. Lung biopsy specimens were examined histologically for MHC class II expression and graded for acute rejection. Bronchoalveolar lavage fluid and plasma were analyzed for cytokines interleukin-2 and interferon-gamma. RESULTS In the 4-hour ischemia group, there was mild diffuse staining of the bronchial epithelium and cellular infiltrate for MHC class II antigens after 1 week with subsequent grade 1-2 rejection. In the 24-hour ischemia group, MHC expression after 1 week revealed strong diffuse staining of bronchial epithelium, vascular endothelium, and cellular infiltrates with a significantly higher grade of rejection. Interleukin-2 and interferon-gamma significantly increased in BAL fluid early after transplantation in both groups. CONCLUSIONS Ischemic injury may predispose the lung allograft to the development of acute rejection, in part, through the upregulation of MHC class II antigen expression and the local release of cytokines.
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Affiliation(s)
- C Serrick
- Montreal Lung Transplant Program, Montreal, Quebec, Canada
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Shennib H, Lee AG, Serrick C, Giaid A. Altered nonspecific lymphocyte cytotoxicity in bronchoalveolar lavage of lung transplant recipients: can it be useful in monitoring rejection or infection? Transplantation 1996; 62:1262-7. [PMID: 8932269 DOI: 10.1097/00007890-199611150-00015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A reliable method for determining the adequacy of immunosuppression of the lung allograft and the absence of rejection or infection does not exist. The purpose of this study is to evaluate the potential role of bronchoalveolar lavage (BAL) in monitoring the adequacy of immunosuppression of lung allografts and in identifying the possible presence of acute rejection (AR) or infection. Thirty-one consecutive lung transplant recipients were subjected to bronchoscopy, transbronchial biopsy, and BAL either as routine surveillance or for decline in lung function (n=68 episodes: 27 normal, 17 infections, six grade IAR, 10 grade II-III AR, and eight obliterative bronchiolitis). Diagnosis was always confirmed histologically and by microbiological workup. Harvested cells underwent phenotypic analysis, and T lymphocytes were subjected to nonspecific lectin-dependent cell-mediated cytotoxicity (LDCMC) and natural killer cytotoxic assays. BAL from normal grafts predominantly contained macrophages (72.8+/-4.4%), with lower neutrophil (13.9+/-4.1%) and lymphocyte (13.2+/-2.2%) populations. Grade II-III AR and infection were associated with an increase in the percentage of neutrophils (43.3+/-8.3% and 33.2+/-3.6%, respectively, P=0.02). BAL of normal allografts contained T cells with low LDCMC (7.4+/-4.5%) and natural killer cytotoxicity (6.3+/-3.4%), whereas grade II-III AR was associated with a significant elevation in LDCMC (32.5+/-11.6%, P=0.019). Pulmonary infection, regardless of its type, was associated with significant elevation in BAL natural killer cytotoxicity (23.9+/-4.9%, P=0.033). Patients with obliterative bronchiolitis, on the other hand, had a mild elevation in the percentage of neutrophils and lymphocytes in BAL, which did not reach statistical significance. However, BAL T-cell LDCMC was significantly elevated (37.6+/-13.7%, P=0.019) compared with normal and infected allografts. We conclude that phenotypic and nonspecific cytotoxic T-cell analysis of BAL, when complimented with microbiological studies, may be useful in surveillance of lung transplant recipients and in determining whether allografts are likely to be quiescent, or possibly affected by acute/chronic rejection or infection, necessitating further definitive action.
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Affiliation(s)
- H Shennib
- The Montreal Lung Transplant Program, Quebec, Canada
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Serrick C, La Franchesca S, Giaid A, Shennib H. Cytokine interleukin-2, tumor necrosis factor-alpha, and interferon-gamma release after ischemia/reperfusion injury in a novel lung autograft animal model. Am J Respir Crit Care Med 1995; 152:277-82. [PMID: 7599835 DOI: 10.1164/ajrccm.152.1.7599835] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Previously, we have reported an increase in the cytokines interleukin-2 (IL-2), tumor necrosis factor-alpha (TNF-alpha), and interferon-gamma (IFN-gamma) early after left lung allotransplantation in dogs. The purpose of this study was to develop a novel model of canine lung autotransplantation and to observe whether ischemia/reperfusion injury alone (in the absence of an allogenic stimulus) would result in this cytokine release as seen in the allograft. Thus, using this model, early changes in cellular and cytokine composition in the lung autograft were monitored through the use of bronchoalveolar lavage (BAL) and plasma. The effects of ischemia/reperfusion injury on lung histology and major histocompatibility class II (MHC II) antigen expression were also observed. Ten mongrel dogs were subjected to left lung autotransplantation. Lungs were stored cold for 4 h, with a warm ischemic time of 1 h. BAL, blood, and biopsy specimens were taken preoperatively and 1 h, 4 h, 24 h, and 1 wk postoperatively. The mean BAL IL-2 levels significantly rose from a preoperative value of 150 +/- 19 pg/ml to 246 +/- 67 pg/ml 4 h after transplantation (p < 0.05), decreasing to preoperative levels after 24 h (128 +/- 54 pg/ml). Plasma levels of IL-2 did not change from preoperative values. In contrast to IL-2, TNF-alpha and IFN-gamma did not change in either BAL or plasma of the autograft.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- C Serrick
- Joint Marseille Montreal Lung Transplant Program, Quebec, Canada
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Shennib H, Serrick C, Saleh D, Adoumie R, Stewart DJ, Giaid A. Alterations in bronchoalveolar lavage and plasma endothelin-1 levels early after lung transplantation. Transplantation 1995; 59:994-8. [PMID: 7709461 DOI: 10.1097/00007890-199504150-00013] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A temporary increase in pulmonary vascular resistance is observed during the first 24 hr following lung allotransplantation. We hypothesized that such early vascular changes are secondary to endothelial injury by ischemia-reperfusion, and that this may be mediated by an increased pulmonary endothelin-1 production/release. To test this hypothesis, radioimmunoassay was used to analyze endothelin-1 levels in bronchoalveolar lavage and plasma taken before surgery and at 1 hr, 4 hr, 24 hr, and 1 week after transplantation. The study was carried out on 2 groups of mongrel dogs. One group was subjected to left single-lung allotransplantation and the other to autotransplantation. Endothelin-1 levels in the bronchoalveolar lavage samples from the lung allografts were significantly increased at 1 (0.70 +/- 0.18 pg/ml) and 4 (1.84 +/- 0.65 pg/ml) hr after transplantation compared with the preoperative value (0.14 +/- 0.05 pg/ml), and declined at 24 (0.85 +/- 0.84 pg/ml) hr after transplantation. Similarly, plasma endothelin-1 levels in the allografts were significantly increased at 1 (2.0 +/- 0.80 pg/ml) and 4 (2.0 +/- 0.71 pg/ml) hr after transplant when compared with preoperative levels (0.54 +/- 0.09 pg/ml). Plasma endothelin-1 levels, however, remained significantly high after 24 hr (1.4 +/- 0.4 pg/ml; P < 0.007) and decreased after 1 week after transplant (0.89 +/- 0.32 pg/ml). On the other hand, endothelin-1 levels in bronchoalveolar lavage from the autograft group remained relatively unchanged; however, plasma levels showed a significant increase at 4 hr (6.6 +/- 1.8 pg/ml) after transplantation compared with preoperative levels (2.8 +/- 0.38 pg/ml). Elevation of endothelin-1 levels early after lung transplantation may play an important role in early high pulmonary vascular resistance and temporary graft dysfunction.
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Affiliation(s)
- H Shennib
- Joint Marseille-Montreal Lung Transplant Program, Montreal General Hospital, Quebec, Canada
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Reis A, Giaid A, Serrick C, Shennib H. Improved outcome of rat lung transplantation with modification of the nonsuture external cuff technique. J Heart Lung Transplant 1995; 14:274-9. [PMID: 7779846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The development of lung transplantation in inbred rats has simplified immunologic studies concerning lung allografts. Unfortunately, up to now, such models have been limited by the high level of surgical expertise required. METHODS In this study 92 rats underwent left lung transplantation with a simplified cuff technique. The feasibility and reliability of this technique was determined by examining graft patency through the use of gross and histologic examination, angiography, and bronchography. RESULTS On gross examination, grafts looked well perfused and ventilated. Histologic examination showed little evidence of foreign body reaction against the Teflon cuff devices, and angiography showed no abnormalities; however, bronchography did show signs of airway stricture at the site of the anastomosis. CONCLUSION We conclude that the nonsuture external cuff technique with Teflon devices represents a reliable, safe, and fast method for performing orthotopic left lung transplantation in the rat.
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Affiliation(s)
- A Reis
- Joint Marseilles-Montreal Lung Transplant Program, Quebec, Canada
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25
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Serrick C, Adoumie R, Giaid A, Shennib H. The early release of interleukin-2, tumor necrosis factor-alpha and interferon-gamma after ischemia reperfusion injury in the lung allograft. Transplantation 1994; 58:1158-62. [PMID: 7992355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A period of cold and warm ischemia is obligatory when performing lung transplantation. Subtle ischemia-reperfusion injury induced in the course of transplantation can pass undetected or cause a short phase of reversible lung dysfunction. We hypothesized that ischemia-reperfusion injury may result in the local release of cytokines that have the capability to mediate acute lung injury early following transplantation. To test this hypothesis, 10 mongrel dogs were subjected to left lung allotransplantation. As performed in the clinical setting, donor lungs were preserved with Eurocollins solution and stored at 4 degrees C for 4 hr, which was followed by 1 hr of warm ischemia. Recipients received standard immunosuppression of cyclosporine, azathioprine, and low dose steroids. Bronchoalveolar lavage (BAL) and open lung biopsies were performed before operation and at approximately 1 hr, 4 hr, 24 hr, and 1 week after transplantation. A significant increase in BAL IL-2 levels was observed 4 hr after surgery (0 hr: 349 +/- 138 pg/ml; 4 hr: 757 +/- 284 pg/ml) (mean +/- SEM) (P < 0.05) which subsequently decreased 24 hr (320 +/- 168 pg/ml) after transplantation. BAL TNF-alpha levels were significantly increased 1 hr after transplantation (P < 0.05) (0 hr: 3.4 +/- 0.65 pg/ml; 1 hr: 13.3 +/- 8.0 pg/ml) returning to baseline after 24 hr (5.8 +/- 2.8 pg/ml). BAL IFN-gamma levels also significantly increased 1 and 4 hr after transplantation (0 hr: 7.2 +/- 2.1 pg/ml; 1 hr: 68.2 +/- 49.2 pg/ml; 4 hr: 301 +/- 131 pg/ml) (P < 0.05). This decreased back to baseline after 24 hr and 1 week (5.2 +/- 1.2 pg/ml and 9.7 +/- 7.9 pg/ml, respectively). There were no changes detected in plasma levels of cytokines. Histology showed evidence of grade 1-2 rejection after 1 week. We conclude that subjection of a lung allograft to standard periods of cold-warm ischemia will result in a temporary early elevation of IL-2, TNF-alpha, and IFN-gamma detectable only in the bronchoalveolar compartment. Such local increase in cytokines in the lung allograft may play an important role in the development of early allograft dysfunction.
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Affiliation(s)
- C Serrick
- Joint Marseille-Montreal Lung Transplant Program, Québec, Canada
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Reis A, Tötsch M, Shennib H, Ofner D, Serrick C, Jamjoom A, Chikhani N, Mikuz G, Margreiter R. Bronchoalveolar lavage: results of sequential, selective techniques in viable murines. Am J Respir Crit Care Med 1994; 150:547-50. [PMID: 8049844 DOI: 10.1164/ajrccm.150.2.8049844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
The purpose of this study was to develop an optimal technique for performing sequential bronchoalveolar lavage (BAL) in a murine animal model. Two general anesthetic regimens and four operative techniques of BAL were tested. Anesthesia by intraperitoneal injection of ketamine hydrochloride (100 mg/kg body wt) resulted in death for four of ten subjects, whereas inhalation of diethyl ether led to death for one of ten subjects. BAL using a balloon catheter under bronchoscopic guidance was comparable with postmortal lavage, tolerated better, and resulted in superior cell retrieval with respect to cell differential (macrophages: 95 +/- 2.3; lymphocytes: 3 +/- 1.2; polymorphonuclear lymphocytes [PNL]: 1.2 +/- 1.4) compared with two other techniques using a bent metal tube/polyethylene tubing combination (macrophages: 19.3 +/- 27.4; lymphocytes: 3.8 +/- 4.3; PNL: 35.5 +/- 35.5) and a bronchoscope/polyethylene tubing combination (macrophages: 11.1 +/- 25.5; lymphocytes: 0.7 +/- 1.0; PNL: 55.8 +/- 41.0). The BAL fluid contained significantly more alveolar macrophages and fewer PNL and epithelial cells (p = 0.0001, p = 0.0025, p = 0.02, respectively). We conclude that the technique using a balloon catheter under bronchoscopic guidance during inhalation of diethyl ether is the procedure of choice and results in a representative sample of BAL.
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Affiliation(s)
- A Reis
- Department of Transplantation, University of Innsbruck, Austria
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Shennib H, Adoumie R, Serrick C, Lulu H, Mulder D. Staple pneumoreduction with fibrin sealant application: a reliable method of transplanting oversized lungs. J Heart Lung Transplant 1994; 13:43-7. [PMID: 8167126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Transplantation of a large lung allograft into a small chest could lead to atelectasis and hemodynamic instability. We developed a technique by which larger-sized lungs could be reduced to fit into smaller recipients. This entails multiple applications of a stapler device to progressively remove excessive lung tissue until the lung fits adequately into the recipient's chest cavity. An experimental animal model was used to test the applicability and safety of this technique. Because air leak from the resected margins was anticipated, we further examined the feasibility of reducing the latter by application of fibrin glue. Eight small mongrel dogs (20 to 25 kg) received left lung allotransplants from eight larger-sized dogs (35 to 40 kg) with the staple pneumoreduction technique. This group was further stratified to receive (group 1A; n = 4) or not receive application of fibrin sealant (group 1B; n = 4) to the stapled resection margins. Group 2 received lungs from similar-sized animals (20 to 25 kg; n = 4 each). Group 3 consisted of size-mismatched animals without pneumoreduction (n = 2). Recipient dogs were compared for facility of chest closure, gas exchange, and hemodynamic stability. The ability of the newly implanted lung to support respiratory function was also assessed by ligation of the opposite pulmonary artery at 4 hours. No difference was noted between groups 1 and 2 in terms of these variables. In sharp contrast, group 3 animals showed a rapid and profound drop in blood pressure after chest closure.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H Shennib
- Joint Marseille-Montreal Lung Transplant Program, Montreal General Hospital, Quebec, Canada
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Abstract
We hypothesized that ischemic insult to the lung allograft may render it more susceptible to rejection. Left canine single-lung allografts were subjected to usual periods of cold and warm ischemia (4 hours and 1 hour, respectively). Bronchoalveolar lavage and open lung biopsies were performed at 0, 1, 4, and 24 hours and 1 week after transplantation. Bronchoalveolar lavage fluid was examined for cellular phenotypes, lymphocyte lectin-mediated cytotoxicity, and natural killer cell cytotoxicity. Open lung biopsy specimens were examined for severity of injury/rejection and MHC class II expression. Within 1 to 4 hours of reimplantation, we observed marked influx of polymorphonuclear leukocytes and lymphocytes and an increase in lectin-mediated cytotoxicity (25.6% +/- 14.8% and 50.6% +/- 20.1% versus 5.4% +/- 7.5% preoperatively; p < 0.05). In addition, natural killer cell cytotoxicity increased from 10.2% +/- 13.5% before transplantation to 20.5% +/- 8.6% 4 hours after transplantation (p < 0.03). By 24 hours MHC class II expression became evident and continued to increase while subtle histologic evidence of rejection appeared by 1 week. We conclude that ischemia-reperfusion injury can alter the local bronchopulmonary milieu, thus rendering it more susceptible to the development of rejection.
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Affiliation(s)
- R Adoumie
- Joint Marseille-Montreal Lung Transplant Program, Quebec, Canada
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