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Combined Assessment of Functional and Metabolic Performance of Human Donor Hearts: Possible Application in Donation After Circulatory Death. Transplantation 2021; 105:1510-1515. [PMID: 33196627 DOI: 10.1097/tp.0000000000003531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Donation after circulatory death (DCD) represents an increasing source of organs. However, evaluating the suitability of DCD hearts for transplantation represents a challenge. Contractile function is the ultimate determinant of recovery. We developed a novel technique in an ex vivo rig for the measurement of contractility using intraventricular balloons. We compared this technique with the measurement of lactate metabolism, the current gold standard. METHODS Human DCD (n = 6) and donation after brain death (n = 6) hearts were preserved by perfusion with a cold oxygenated crystalloid solution for 4 h, transferred to a blood perfusion rig at 37 °C where balloons were inserted into the left (LV) and right (RV) ventricles to measure developed pressure (DP = systolic minus diastolic). Perfusate lactate levels were measured for metabolic assessment. Concordance between LVDP and lactate was assessed during 4 h using cutoffs for LVDP of 70 mm Hg and for lactate of 10 mmol/L. RESULTS Measurements of contractile function (LVDP) and metabolism (lactate levels) were deemed concordant in 7 hearts with either a high LVDP (mean 100 mm Hg) with low lactate (mean 6.7 mmol/L)) or a low LVDP (15 mm Hg) with high lactate (mean 17.3 mmol/). In the remaining 5 hearts, measurements were deemed discordant: 4 hearts had high LVDP (mean 124 mm Hg), despite high lactate levels 17.3 mmol/L) and 1 had low LVDP (54 mm Hg) but low lactate (6.9 mmol/L). CONCLUSIONS The intraventricular balloon technique provides useful information regarding contractile recovery of donor hearts that if combined with lactate metabolism has potential application for the evaluation of DCD and marginal donation after brain death hearts before transplant.
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A Multi-Mode System for Myocardial Functional and Physiological Assessment during Ex Situ Heart Perfusion. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:303-313. [PMID: 33343033 DOI: 10.1182/ject-2000034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022]
Abstract
Ex situ heart perfusion (ESHP) has proven to be an important and valuable step toward better preservation of donor hearts for heart transplantation. Currently, few ESHP systems allow for a convenient functional and physiological evaluation of the heart. We sought to establish a simple system that provides functional and physiological assessment of the heart during ESHP. The ESHP circuit consists of an oxygenator, a heart-lung machine, a heater-cooler unit, an anesthesia gas blender, and a collection funnel. Female Yorkshire pig hearts (n = 10) had del Nido cardioplegia (4°C) administered, excised, and attached to the perfusion system. Hearts were perfused retrogradely into the aortic root for 2 hours before converting the system to an isovolumic mode or a working mode for further 2 hours. Blood samples were analyzed to measure metabolic parameters. During the isovolumic mode (n = 5), a balloon inserted in the left ventricular (LV) cavity was inflated so that an end-diastolic pressure of 6-8 mmHg was reached. During the working mode (n = 5), perfusion in the aortic root was redirected into left atrium (LA) using a compliance chamber which maintained an LA pressure of 6-8 mmHg. Another compliance chamber was used to provide an afterload of 40-50 mmHg. Hemodynamic and metabolic conditions remained stable and consistent for a period of 4 hours of ESHP in both isovolumic mode (LV developed pressure: 101.0 ± 3.5 vs. 99.7 ± 6.8 mmHg, p = .979, at 2 and 4 hours, respectively) and working mode (LV developed pressure: 91.0 ± 2.6 vs. 90.7 ± 2.5 mmHg, p = .942, at 2 and 4 hours, respectively). The present study proposed a novel ESHP system that enables comprehensive functional and metabolic assessment of large mammalian hearts. This system allowed for stable myocardial function for up to 4 hours of perfusion, which would offer great potential for the development of translational therapeutic protocols to improve dysfunctional donated hearts.
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Wang L, MacGowan GA, Ali S, Dark JH. Ex situ heart perfusion: The past, the present, and the future. J Heart Lung Transplant 2020; 40:69-86. [PMID: 33162304 DOI: 10.1016/j.healun.2020.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 01/06/2023] Open
Abstract
Despite the advancements in medical treatment, mechanical support, and stem cell therapy, heart transplantation remains the most effective treatment for selected patients with advanced heart failure. However, with an increase in heart failure prevalence worldwide, the gap between donor hearts and patients on the transplant waiting list keeps widening. Ex situ machine perfusion has played a key role in augmenting heart transplant activities in recent years by enabling the usage of donation after circulatory death hearts, allowing longer interval between procurement and implantation, and permitting the safe use of some extended-criteria donation after brainstem death hearts. This exciting field is at a hinge point, with 1 commercially available heart perfusion machine, which has been used in hundreds of heart transplantations, and a number of devices being tested in the pre-clinical and Phase 1 clinical trial stage. However, no consensus has been reached over the optimal preservation temperature, perfusate composition, and perfusion parameters. In addition, there is a lack of objective measurement for allograft quality and viability. This review aims to comprehensively summarize the lessons about ex situ heart perfusion as a platform to preserve, assess, and repair donor hearts, which we have learned from the pre-clinical studies and clinical applications, and explore its exciting potential of revolutionizing heart transplantation.
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Affiliation(s)
- Lu Wang
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Guy A MacGowan
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom; Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Simi Ali
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John H Dark
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
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Fuchs M, Schibilsky D, Zeh W, Berchtold-Herz M, Beyersdorf F, Siepe M. Does the heart transplant have a future? Eur J Cardiothorac Surg 2020; 55:i38-i48. [PMID: 31106338 PMCID: PMC6537946 DOI: 10.1093/ejcts/ezz107] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/29/2019] [Accepted: 02/15/2019] [Indexed: 12/11/2022] Open
Abstract
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Heart failure has remained the leading cause of death globally for the last 15 years—and its prevalence will continue to rise. Fifty years ago, heart failure management was enriched by the possibility of a heart transplant. Despite impressive improvements in medical treatment for heart failure, a heart transplant remains the most effective long-lasting treatment for advanced heart failure in terms of mortality and quality of life. However, donor and recipient characteristics have changed dramatically in recent years, leading to more complex decision-making regarding organ acceptance and to more demanding operations and postoperative management. With improving pathophysiological understanding in the last decades, today’s scientific interest still focuses on basic knowledge. How to retrieve and conserve organs to minimize ischaemic injury; how best to allocate them, considering the likelihood of success (developing a heart-allocation scoring system similar to that for lung allocation); how to match donor/recipient characteristics (ABO blood-group antigen compatibility versus incompatibility); and how to avoid graft failure, rejection and secondary morbidities such as malignomas and cardiac allograft vasculopathy after the heart transplant—all these factors remain fundamental challenges in today’s transplant medicine. The use of ex vivo perfusion (e.g. via the Organ Care System®, TransMedics, Andover, MA, USA) may play an important role in this change. Remarkably, there are huge regional divergences in current transplant practices: Whereas the number of transplants continues to rise in most Eurotransplant countries and other major transplant networks, there are some countries in which transplant numbers are static or even dropping (as in Germany). This difference results in wide variations across different countries as to how advanced heart failure is treated using mechanical circulatory-assist devices.
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Affiliation(s)
- Matthias Fuchs
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Corresponding author. Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Südring 15, 79189 Bad Krozingen, Germany. Tel: +49-7633-4020; fax: +49-7633-4029909; e-mail: (M. Fuchs)
| | - David Schibilsky
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang Zeh
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Ribeiro RVP, Alvarez JS, Yu F, Adamson MB, Paradiso E, Hondjeu ARM, Xin L, Gellner B, Degen M, Bissoondath V, Meineri M, Rao V, Badiwala MV. Comparing Donor Heart Assessment Strategies During Ex Situ Heart Perfusion to Better Estimate Posttransplant Cardiac Function. Transplantation 2020; 104:1890-1898. [PMID: 32826843 DOI: 10.1097/tp.0000000000003374] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Ex situ heart perfusion (ESHP) limits ischemic periods and enables continuous monitoring of donated hearts; however, a validated assessment method to predict cardiac performance has yet to be established. We compare biventricular contractile and metabolic parameters measured during ESHP to determine the best evaluation strategy to estimate cardiac function following transplantation. METHODS Donor pigs were assigned to undergo beating-heart donation (n = 9) or donation after circulatory death (n = 8) induced by hypoxia. Hearts were preserved for 4 hours with ESHP while invasive and noninvasive (NI) biventricular contractile, and metabolic assessments were performed. Following transplantation, hearts were evaluated at 3 hours of reperfusion. Spearman correlation was used to determine the relationship between ESHP parameters and posttransplant function. RESULTS We performed 17 transplants; 14 successfully weaned from bypass (beating-heart donation versus donation after circulatory death; P = 0.580). Left ventricular invasive preload recruitable stroke work (PRSW) (r = 0.770; P = 0.009), NI PRSW (r = 0.730; P = 0.001), and NI maximum elastance (r = 0.706; P = 0.002) strongly correlated with cardiac index (CI) following transplantation. Right ventricular NI PRSW moderately correlated to CI following transplantation (r = 0.688; P = 0.003). Lactate levels were weakly correlated with CI following transplantation (r = -0.495; P = 0.043). None of the echocardiography measurements correlated with cardiac function following transplantation. CONCLUSIONS Left ventricular functional parameters, especially ventricular work and reserve, provided the best estimation of myocardial performance following transplantation. Furthermore, simple NI estimates of ventricular function proved useful in this setting. Right ventricular and metabolic measurements were limited in their ability to correlate with myocardial recovery. This emphasizes the need for an ESHP platform capable of assessing myocardial contractility and suggests that metabolic parameters alone do not provide a reliable evaluation.
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Affiliation(s)
- Roberto Vanin Pinto Ribeiro
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Juglans Souto Alvarez
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Frank Yu
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Mitchell Brady Adamson
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Emanuela Paradiso
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Arnaud Romeo Mbadjeu Hondjeu
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Liming Xin
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Mechanical Engineering, University of Toronto, Toronto, Canada
| | - Bryan Gellner
- Department of Mechanical Engineering, University of Toronto, Toronto, Canada
| | - Maja Degen
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Ved Bissoondath
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Massimiliano Meineri
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Mitesh Vallabh Badiwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Canada
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6
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Gellner B, Xin L, Pinto Ribeiro RV, Bissoondath V, Adamson MB, Yu F, Lu P, Paradiso E, Mbadjeu Hondjeu AR, Simmons CA, Badiwala MV. The implementation of physiological afterload during ex situ heart perfusion augments prediction of posttransplant function. Am J Physiol Heart Circ Physiol 2019; 318:H25-H33. [PMID: 31774696 DOI: 10.1152/ajpheart.00427.2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Ex situ heart perfusion (ex situ heart perfusion) is an emerging technique that aims to increase the number of organs available for transplantation by augmenting both donor heart preservation and evaluation. Traditionally, ex situ heart perfusion has been performed in an unloaded Langendorff mode, though more recently groups have begun to use pump-supported working mode (PSWM) and passive afterload working mode (PAWM) to enable contractile evaluation during ex situ heart perfusion. To this point, however, neither the predictive effectiveness of the two working modes nor the predictive power of individual contractile parameters has been analyzed. In this article, we use our previously described system to analyze the predictive relevance of a multitude of contractile parameters measured in each working mode. Ten porcine hearts were excised and perfused ex situ in Langendorff mode for 4 h, evaluated using pressure-volume catheterization in both PSWM and PAWM, and transplanted into size-matched recipient pigs. After 3 h, hearts were weaned from cardiopulmonary bypass and evaluated. When correlating posttransplant measurements to their ex situ counterparts, we report that parameters measured in both modes show sufficient power (Spearman rank coefficient > 0.7) in predicting global posttransplant function, characterized by cardiac index and preload recruitable stroke work. For the prediction of specific posttransplant systolic and diastolic function, however, a large discrepancy between the two working modes was observed. With 9 of 10 measured posttransplant parameters showing stronger correlation with counterparts measured in PAWM, it is concluded that PAWM allows for a more detailed and nuanced prediction of posttransplant function than can be made in PSWM.NEW & NOTEWORTHY Ex situ heart perfusion has been proposed as a means to augment the organ donor pool by improving organ preservation and evaluation between donation and transplantation. Using our multimodal perfusion system, we analyzed the impact of using a "passive afterload working mode" for functional evaluation as compared with the more traditional "pump-supported working mode." Our data suggests that passive afterload working mode allows for a more nuanced prediction of posttransplant function in porcine hearts.
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Affiliation(s)
- Bryan Gellner
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada.,Translational Biology and Engineering Program, Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
| | - Liming Xin
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Roberto Vanin Pinto Ribeiro
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Ved Bissoondath
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mitchell B Adamson
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Frank Yu
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Pengzhou Lu
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Emanuela Paradiso
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Arnaud Romeo Mbadjeu Hondjeu
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Craig A Simmons
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada.,Translational Biology and Engineering Program, Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Mitesh V Badiwala
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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7
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White CW, Messer SJ, Large SR, Conway J, Kim DH, Kutsogiannis DJ, Nagendran J, Freed DH. Transplantation of Hearts Donated after Circulatory Death. Front Cardiovasc Med 2018; 5:8. [PMID: 29487855 PMCID: PMC5816942 DOI: 10.3389/fcvm.2018.00008] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 01/19/2018] [Indexed: 12/17/2022] Open
Abstract
Cardiac transplantation has become limited by a critical shortage of suitable organs from brain-dead donors. Reports describing the successful clinical transplantation of hearts donated after circulatory death (DCD) have recently emerged. Hearts from DCD donors suffer significant ischemic injury prior to organ procurement; therefore, the traditional approach to the transplantation of hearts from brain-dead donors is not applicable to the DCD context. Advances in our understanding of ischemic post-conditioning have facilitated the development of DCD heart resuscitation strategies that can be used to minimize ischemia-reperfusion injury at the time of organ procurement. The availability of a clinically approved ex situ heart perfusion device now allows DCD heart preservation in a normothermic beating state and minimizes exposure to incremental cold ischemia. This technology also facilitates assessments of organ viability to be undertaken prior to transplantation, thereby minimizing the risk of primary graft dysfunction. The application of a tailored approach to DCD heart transplantation that focuses on organ resuscitation at the time of procurement, ex situ preservation, and pre-transplant assessments of organ viability has facilitated the successful clinical application of DCD heart transplantation. The transplantation of hearts from DCD donors is now a clinical reality. Investigating ways to optimize the resuscitation, preservation, evaluation, and long-term outcomes is vital to ensure a broader application of DCD heart transplantation in the future.
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Affiliation(s)
| | - Simon J Messer
- Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Stephen R Large
- Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Daniel H Kim
- Cardiology, University of Alberta, Edmonton, AB, Canada
| | | | - Jayan Nagendran
- Cardiac Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H Freed
- Cardiac Surgery, University of Alberta, Edmonton, AB, Canada.,Department of Physiology, University of Alberta, Edmonton, AB, Canada.,Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
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8
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White CW, Ambrose E, Müller A, Li Y, Le H, Hiebert B, Arora R, Lee TW, Dixon I, Tian G, Nagendran J, Hryshko L, Freed D. Assessment of donor heart viability during ex vivo heart perfusion. Can J Physiol Pharmacol 2015; 93:893-901. [DOI: 10.1139/cjpp-2014-0474] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Ex vivo heart perfusion (EVHP) may facilitate resuscitation of discarded donor hearts and expand the donor pool; however, a reliable means of demonstrating organ viability prior to transplantation is required. Therefore, we sought to identify metabolic and functional parameters that predict myocardial performance during EVHP. To evaluate the parameters over a broad spectrum of organ function, we obtained hearts from 9 normal pigs and 37 donation after circulatory death pigs and perfused them ex vivo. Functional parameters obtained from a left ventricular conductance catheter, oxygen consumption, coronary vascular resistance, and lactate concentration were measured, and linear regression analyses were performed to identify which parameters best correlated with myocardial performance (cardiac index: mL·min–1·g–1). Functional parameters exhibited excellent correlation with myocardial performance and demonstrated high sensitivity and specificity for identifying hearts at risk of poor post-transplant function (ejection fraction: R2 = 0.80, sensitivity = 1.00, specificity = 0.85; stroke work: R2 = 0.76, sensitivity = 1.00, specificity = 0.77; minimum dP/dt: R2 = 0.74, sensitivity = 1.00, specificity = 0.54; tau: R2 = 0.51, sensitivity = 1.00, specificity = 0.92), whereas metabolic parameters were limited in their ability to predict myocardial performance (oxygen consumption: R2 = 0.28; coronary vascular resistance: R2 = 0.20; lactate concentration: R2 = 0.02). We concluded that evaluation of functional parameters provides the best assessment of myocardial performance during EVHP, which highlights the need for an EVHP device capable of assessing the donor heart in a physiologic working mode.
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Affiliation(s)
- Christopher W. White
- Cardiac Surgery, St. Boniface Hospital, University of Manitoba, 409 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Emma Ambrose
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Alison Müller
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Yun Li
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Hoa Le
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Brett Hiebert
- Cardiac Surgery, St. Boniface Hospital, University of Manitoba, 409 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Rakesh Arora
- Cardiac Surgery, St. Boniface Hospital, University of Manitoba, 409 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
- National Research Council Institute for Biodiagnostics, 435 Ellice Avenue, Winnipeg, MB R3B 1Y6, Canada
| | - Trevor W. Lee
- Anesthesia and Perioperative Medicine, St. Boniface Hospital, University of Manitoba, 409 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Ian Dixon
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Ganghong Tian
- National Research Council Institute for Biodiagnostics, 435 Ellice Avenue, Winnipeg, MB R3B 1Y6, Canada
| | - Jayan Nagendran
- Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 2D4.34 WMC, 8440-112 Street, Edmonton, AB T6G 2B7, Canada
| | - Larry Hryshko
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Darren Freed
- Cardiac Surgery, St. Boniface Hospital, University of Manitoba, 409 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
- Institute of Cardiovascular Sciences, St. Boniface Research Center, 351 Taché Avenue, Winnipeg, MB R2H 2A6, Canada
- National Research Council Institute for Biodiagnostics, 435 Ellice Avenue, Winnipeg, MB R3B 1Y6, Canada
- Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 2D4.34 WMC, 8440-112 Street, Edmonton, AB T6G 2B7, Canada
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9
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White CW, Hasanally D, Mundt P, Li Y, Xiang B, Klein J, Müller A, Ambrose E, Ravandi A, Arora RC, Lee TW, Hryshko LV, Large S, Tian G, Freed DH. A whole blood–based perfusate provides superior preservation of myocardial function during ex vivo heart perfusion. J Heart Lung Transplant 2015; 34:113-121. [DOI: 10.1016/j.healun.2014.09.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 09/04/2014] [Accepted: 09/19/2014] [Indexed: 11/29/2022] Open
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10
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Mownah OA, Khurram MA, Ray C, Kanwar A, Stamp S, Rees D, Brassil J, Majo J, Dark JH, Carter NM, Talbot D. Development of an ex vivo technique to achieve reanimation of hearts sourced from a porcine donation after circulatory death model. J Surg Res 2014; 189:326-34. [DOI: 10.1016/j.jss.2014.02.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Revised: 01/02/2014] [Accepted: 02/22/2014] [Indexed: 10/25/2022]
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11
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Longnus SL, Mathys V, Dornbierer M, Dick F, Carrel TP, Tevaearai HT. Heart transplantation with donation after circulatory determination of death. Nat Rev Cardiol 2014; 11:354-63. [DOI: 10.1038/nrcardio.2014.45] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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12
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Sourdon J, Dornbierer M, Huber S, Gahl B, Carrel TP, Tevaearai HT, Longnus SL. Cardiac transplantation with hearts from donors after circulatory declaration of death: haemodynamic and biochemical parameters at procurement predict recovery following cardioplegic storage in a rat model. Eur J Cardiothorac Surg 2013; 44:e87-96. [PMID: 23504113 DOI: 10.1093/ejcts/ezt142] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Donation after circulatory declaration of death (DCDD) could significantly improve the number of cardiac grafts for transplantation. Graft evaluation is particularly important in the setting of DCDD given that conditions of cardio-circulatory arrest and warm ischaemia differ, leading to variable tissue injury. The aim of this study was to identify, at the time of heart procurement, means to predict contractile recovery following cardioplegic storage and reperfusion using an isolated rat heart model. Identification of reliable approaches to evaluate cardiac grafts is key in the development of protocols for heart transplantation with DCDD. METHODS Hearts isolated from anaesthetized male Wistar rats (n = 34) were exposed to various perfusion protocols. To simulate DCDD conditions, rats were exsanguinated and maintained at 37°C for 15-25 min (warm ischaemia). Isolated hearts were perfused with modified Krebs-Henseleit buffer for 10 min (unloaded), arrested with cardioplegia, stored for 3 h at 4°C and then reperfused for 120 min (unloaded for 60 min, then loaded for 60 min). Left ventricular (LV) function was assessed using an intraventricular micro-tip pressure catheter. Statistical significance was determined using the non-parametric Spearman rho correlation analysis. RESULTS After 120 min of reperfusion, recovery of LV work measured as developed pressure (DP)-heart rate (HR) product ranged from 0 to 15 ± 6.1 mmHg beats min(-1) 10(-3) following warm ischaemia of 15-25 min. Several haemodynamic parameters measured during early, unloaded perfusion at the time of heart procurement, including HR and the peak systolic pressure-HR product, correlated significantly with contractile recovery after cardioplegic storage and 120 min of reperfusion (P < 0.001). Coronary flow, oxygen consumption and lactate dehydrogenase release also correlated significantly with contractile recovery following cardioplegic storage and 120 min of reperfusion (P < 0.05). CONCLUSIONS Haemodynamic and biochemical parameters measured at the time of organ procurement could serve as predictive indicators of contractile recovery. We believe that evaluation of graft suitability is feasible prior to transplantation with DCDD, and may, consequently, increase donor heart availability.
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Affiliation(s)
- Joevin Sourdon
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
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13
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Dornbierer M, Stadelmann M, Sourdon J, Gahl B, Cook S, Carrel TP, Tevaearai HT, Longnus SL. Early reperfusion hemodynamics predict recovery in rat hearts: a potential approach towards evaluating cardiac grafts from non-heart-beating donors. PLoS One 2012; 7:e43642. [PMID: 22928009 PMCID: PMC3424125 DOI: 10.1371/journal.pone.0043642] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 07/24/2012] [Indexed: 11/19/2022] Open
Abstract
Aims Cardiac grafts from non-heartbeating donors (NHBDs) could significantly increase organ availability and reduce waiting-list mortality. Reluctance to exploit hearts from NHBDs arises from obligatory delays in procurement leading to periods of warm ischemia and possible subsequent contractile dysfunction. Means for early prediction of graft suitability prior to transplantation are thus required for development of heart transplantation programs with NHBDs. Methods and Results Hearts (n = 31) isolated from male Wistar rats were perfused with modified Krebs-Henseleit buffer aerobically for 20 min, followed by global, no-flow ischemia (32°C) for 30, 50, 55 or 60 min. Reperfusion was unloaded for 20 min, and then loaded, in working-mode, for 40 min. Left ventricular (LV) pressure was monitored using a micro-tip pressure catheter introduced via the mitral valve. Several hemodynamic parameters measured during early, unloaded reperfusion correlated significantly with LV work after 60 min reperfusion (p<0.001). Coronary flow and the production of lactate and lactate dehydrogenase (LDH) also correlated significantly with outcomes after 60 min reperfusion (p<0.05). Based on early reperfusion hemodynamic measures, a composite, weighted predictive parameter, incorporating heart rate (HR), developed pressure (DP) and end-diastolic pressure, was generated and evaluated against the HR-DP product after 60 min of reperfusion. Effective discriminating ability for this novel parameter was observed for four HR*DP cut-off values, particularly for ≥20 *103 mmHg*beats*min−1 (p<0.01). Conclusion Upon reperfusion of a NHBD heart, early evaluation, at the time of organ procurement, of cardiac hemodynamic parameters, as well as easily accessible markers of metabolism and necrosis seem to accurately predict subsequent contractile recovery and could thus potentially be of use in guiding the decision of accepting the ischemic heart for transplantation.
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Affiliation(s)
- Monika Dornbierer
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
| | - Mathieu Stadelmann
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
- Cardiology, University & Hospital, Fribourg, Switzerland
| | - Joevin Sourdon
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
- University of Auvergne, Institute of Technology, Clermont-Ferrand, France
| | - Brigitta Gahl
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
| | - Stéphane Cook
- Cardiology, University & Hospital, Fribourg, Switzerland
| | - Thierry P. Carrel
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
| | - Hendrik T. Tevaearai
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
- * E-mail:
| | - Sarah L. Longnus
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
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Colah S, Freed DH, Mundt P, Germscheid S, White P, Ali A, Tian G, Large S, Falter F. Ex vivo perfusion of the swine heart as a method for pre-transplant assessment. Perfusion 2012; 27:408-13. [PMID: 22695793 DOI: 10.1177/0267659112449035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We describe a cost-effective, reproducible circuit in a porcine, ex vivo, continuous warm-blood, bi-ventricular, working heart model that has future possibilities for pre-transplant assessment of marginal hearts donated from brain stem dead donors and hearts donated after circulatory determination of death (DCDD). In five consecutive experiments over five days, pressure volume loops were performed. During working mode, the left ventricular end systolic pressure volume relationship (LV ESPVR) was 23.1±11.1 mmHg/ml and the LV preload recruitable stroke work (PRSW) was 67.8±7.2. (Standard PVAN analysis software) (Millar Instruments, Houston, TX, USA) All five hearts were perfused for 219±64 minutes and regained normal cardiac function on the perfusion system.They displayed a significant upward and leftward shift of the end systolic pressure volume relationship, a significant increase in preload recruitable stroke work and minimal stiffness. These hearts could potentially be considered for transplantation. The circuit was effective during reperfusion and working modes whilst proving to be successful in maintaining cardiac function in excess of four hours. Using an autologous prime of approximately 20% haematocrit (Hct), electrolytes and blood gases were easy to control within this period using standard perfusion techniques.
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Affiliation(s)
- S Colah
- Cambridge Perfusion Services, Papworth Hospital, Cambridge, UK.
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15
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Post-mortem tissue-type plasminogen activator preserves graft function of hearts harvested from non-pre-treated non-heart-beating donors. J Heart Lung Transplant 2010; 29:888-93. [DOI: 10.1016/j.healun.2010.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Revised: 04/07/2010] [Accepted: 04/07/2010] [Indexed: 11/20/2022] Open
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Cardiac reanimation for donor heart transplantation after cardiocirculatory death. J Heart Lung Transplant 2010; 29:747-55. [DOI: 10.1016/j.healun.2010.02.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 02/19/2010] [Accepted: 02/22/2010] [Indexed: 11/20/2022] Open
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Ohki S, Oshima K, Tsutsumi H, Koike N, Matsumoto K, Takeyoshi I. The suppression of proinflammatory cytokines improves heart function from non-heart-beating donors following transplantation in a canine model. Int Heart J 2009; 50:235-45. [PMID: 19367033 DOI: 10.1536/ihj.50.235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We evaluated the effectiveness of a suppressant of the production of proinflammatory cytokines such as interleukin (IL)-1 and tumor necrosis factor (TNF)-alpha on a canine heart transplantation model with non-heart-beating donors (NHBDs).Adult mongrel dogs were divided into 3 groups of 5: a control group; FR-1 in which donors were given FR167653, a potent suppressant of IL-1beta and TNF-alpha production; and FR-2 in which both donors and recipients were given FR167653. After measuring the baseline hemodynamic parameters, including cardiac output (CO), left ventricular pressure (LVP), and maximum and minimum rates of increase in LVP (+/- LVdp/dt), FR167653 was administered continuously for 30 minutes before ischemia in the FR-1 and FR-2 groups. Cardiac arrest was obtained by rapid exsanguination from the abdominal aorta and inferior vena cava. The organ was left in the cadaver for 30 minutes. The coronary vascular beds were washed out with 4 degrees C Celsior solution, and then the donor heart was preserved in 4 degrees C Celsior solution for 4 hours. The donor heart was transplanted orthotopically with cardiopulmonary bypass (CPB). FR167653 was administered intravenously from 15 minutes before aortic-cross clamping until the end of the experiment in the FR-2 group. The recipient was weaned from CPB 1 hour after reperfusion. We compared the hemodynamic parameters at 3 hours after reperfusion with the preoperative values in donor animals with the right atrial pressure at 10 mmHg and a 5 microg/kg/min dopamine infusion. Histopathological analysis was also performed.There were no significant differences in the recovery rates of the hemodynamic parameters between the control and FR-1 groups and between the FR-1 and FR-2 groups. However, the recovery rates of CO and -LVdp/dt in the FR-2 group were significantly (P < 0.05) higher than those in the control group. Histopathological analysis showed that myofilaments were better preserved in the FR-2 group compared with the control group.The administration of a suppressant of proinflammatory cytokines before both ischemia and reperfusion effectively preserves donor heart function after transplantation with NHBDs.
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Affiliation(s)
- Shigeru Ohki
- Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
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19
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20
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Collins MJ, Moainie SL, Griffith BP, Poston RS. Preserving and evaluating hearts with ex vivo machine perfusion: an avenue to improve early graft performance and expand the donor pool. Eur J Cardiothorac Surg 2008; 34:318-25. [PMID: 18539041 PMCID: PMC2649718 DOI: 10.1016/j.ejcts.2008.03.043] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Revised: 03/04/2008] [Accepted: 03/06/2008] [Indexed: 11/21/2022] Open
Abstract
Cardiac transplantation remains the first choice for the surgical treatment of end stage heart failure. An inadequate supply of donor grafts that meet existing criteria has limited the application of this therapy to suitable candidates and increased interest in extended criteria donors. Although cold storage (CS) is a time-tested method for the preservation of hearts during the ex vivo transport interval, its disadvantages are highlighted in hearts from the extended criteria donor. In contrast, transport of high-risk hearts using hypothermic machine perfusion (MP) provides continuous support of aerobic metabolism and ongoing washout of metabolic byproducts. Perhaps more importantly, monitoring the organ's response to this intervention provides insight into the viability of a heart initially deemed as extended criteria. Obviously, ex vivo MP introduces challenges, such as ensuring homogeneous tissue perfusion and avoiding myocardial edema. Though numerous groups have experimented with this technology, the best perfusate and perfusion parameters needed to achieve optimal results remain unclear. In the present review, we outline the benefits of ex vivo MP with particular attention to how the challenges can be addressed in order to achieve the most consistent results in a large animal model of the ideal heart donor. We provide evidence that MP can be used to resuscitate and evaluate hearts from animal and human extended criteria donors, including the non-heart beating donor, which we feel is the most compelling argument for why this technology is likely to impact the donor pool.
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Affiliation(s)
- Michael J. Collins
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, N4W94 22 S. Greene St., Baltimore, MD, 21201, United States
| | - Sina L. Moainie
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, N4W94 22 S. Greene St., Baltimore, MD, 21201, United States
| | - Bartley P. Griffith
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, N4W94 22 S. Greene St., Baltimore, MD, 21201, United States
| | - Robert S. Poston
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, N4W94 22 S. Greene St., Baltimore, MD, 21201, United States
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Inci I, Zhai W, Arni S, Inci D, Hillinger S, Lardinois D, Vogt P, Weder W. Fibrinolytic Treatment Improves the Quality of Lungs Retrieved From Non-Heart-Beating Donors. J Heart Lung Transplant 2007; 26:1054-60. [DOI: 10.1016/j.healun.2007.07.033] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2007] [Revised: 07/13/2007] [Accepted: 07/18/2007] [Indexed: 11/29/2022] Open
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Pfeifer L, Gruenwald I, Welker A, Stahn RM, Stein K, Rex A. Fluorimetric characterisation of metabolic activity of ex vivo perfused pig hearts. BIOMED ENG-BIOMED TE 2007; 52:193-9. [PMID: 17408379 DOI: 10.1515/bmt.2007.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Autofluorescence of tissues and organs is an indicator of the physiological state of cells. The aim of the study was to investigate whether fluorimetric determination of the redox state of the ex vivo perfused pig heart can provide fast online detection of progressive changes in heart muscle tissue. Measurements on six organs perfused in a four-chamber working heart model were performed using a spectroscopic method exploiting the specific and different fluorescence lifetimes of intrinsic fluorophores such as NADH and flavins and providing a means of internal signal referencing. It was shown that the redox potential of heart muscle tissue can be assessed by fluorescence measurement. In the steady-state phase of the beating heart, spectroscopic measurements revealed a change in redox state from an initial constant level to a continuous decrease, accompanied by a decrease in heart performance and indications of changes in electrolyte equilibrium (K(+) concentration). At the same time, troponin I levels in the perfusate increased. The results indicate that fluorimetric determination of heart muscle metabolic activity yields reliable information about the functional status of the ex vivo heart and may be advantageous for the optimisation of ex vivo organ models.
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Affiliation(s)
- Lutz Pfeifer
- IOM Innovative Optische Messtechnik GmbH, Berlin, Germany.
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23
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Collins MJ, Ozeki T, Zhuo J, Gu J, Gullapalli R, Pierson RN, Griffith BP, Fedak PWM, Poston RS. Use of diffusion tensor imaging to predict myocardial viability after warm global ischemia: possible avenue for use of non-beating donor hearts. J Heart Lung Transplant 2007; 26:376-83. [PMID: 17403480 DOI: 10.1016/j.healun.2006.12.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Revised: 11/10/2006] [Accepted: 12/12/2006] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND The assessment of myocardial viability after global warm ischemia (WI) but before reperfusion is challenging. We hypothesized that fractional anisotropy (FA), a magnetic resonance imaging (MRI) parameter of water diffusion that characterizes cellular integrity within tissues, provides a rapid and useful method for evaluating the viability of hearts after WI. METHODS Dog hearts were exposed to 60 minutes of WI after exanguination, explanted and preserved in a cold, non-beating state for 6 hours, using continuous perfusion (CP) or static cold storage (CS). Toward the end of preservation, a global FA assessment, acquired using MRI, was compared with analyses obtained from myocardial biopsies that included adenosine triphosphate (ATP), endothelin-1 (ET-1) and caspase-3 levels, light microscopy and tetrazolium staining. Functional recovery was analyzed after restoration of blood flow on a non-working Langendorff preparation. RESULTS FA measured at the end of CP showed strong correlations with all parameters of functional recovery (developed pressure, R = 0.60; dP/dt, R = 0.96; -dP/dt, R = 0.96). Although FA also correlated with tissue levels of ATP, ET-1 and caspase-3 (R = 0.77, -0.84, -0.64), recovery of myocardial function did not correlate with these markers or any other conventional analyses of myocardial injury (troponin I, changes on light microscopy or tetrazolium staining). CONCLUSIONS FA, an MRI-based parameter that indicates cellular integrity, was found to reflect better myocardial ATP stores, less induction of ET-1 and caspase-3 and improved functional recovery of hearts after global WI. As a clinically applicable tool capable of rapidly differentiating reversible from lethal injury, diffusion tensor imaging may prove useful in the eventual adoption of non-beating donor hearts for transplantation.
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Affiliation(s)
- Michael J Collins
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical System, Baltimore, Maryland 21201, USA
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Osaki S, Ishino K, Kotani Y, Honjo O, Suezawa T, Kanki K, Sano S. Resuscitation of Non-Beating Donor Hearts Using Continuous Myocardial Perfusion: The Importance of Controlled Initial Reperfusion. Ann Thorac Surg 2006; 81:2167-71. [PMID: 16731148 DOI: 10.1016/j.athoracsur.2006.01.066] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Revised: 01/15/2006] [Accepted: 01/18/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Warm ischemia is a major cause of cardiac allograft failure in transplants from non-heart-beating donors. To minimize myocardial ischemia, we used a continuous myocardial perfusion technique for resuscitation of donor hearts. The purpose of the present study was to investigate an optimal duration of controlled initial reperfusion. METHODS Cardiac arrest was induced by asphyxia in 18 donor pigs. The hearts were harvested 30 minutes after global warm ischemia. Continuous myocardial reperfusion was immediately commenced from the aortic root with blood cardioplegic solution (20 degrees C, 40 mm Hg) and then with oxygenated blood (20 degrees to 37 degrees C, 40 to 60 mm Hg). Animals were divided into three groups according to the duration of the initial reperfusion: group I = 5 minutes, group II = 20 minutes, and group III = 60 minutes. Orthotopic transplantation was performed while keeping the heart beating by continuous myocardial perfusion. Cardiac function was evaluated before anoxia and after transplantation. Lactate extractions were determined during reperfusion. Myocardial edema was assessed by heart weight and posterior wall thickness of the left ventricle. RESULTS Recovery rates of cardiac function in group II hearts after transplantation were better than in groups I and III (cardiac output, 61% +/- 9% versus 41% +/- 5% versus 44% +/- 4%, respectively; p < 0.05; left ventricular end-systolic pressure-volume ratio, 64% +/- 8% versus 36% +/- 9% versus 42% +/- 6%, respectively; p < 0.05). Lactate extractions in groups II and III returned to 0 within 20 minutes of reperfusion. Myocardial edema after transplantation in group II hearts was less than in groups I and III. CONCLUSIONS The best recovery was observed in the non-beating donor hearts resuscitated by continuous myocardial perfusion when the initial controlled reperfusion with lukewarm blood cardioplegic solution at 40 mm Hg lasted for 20 minutes.
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Affiliation(s)
- Satoru Osaki
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
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Hirota M, Ishino K, Fukumasu I, Yoshida K, Mohri S, Shimizu J, Kajiya F, Sano S. Prediction of functional recovery of 60-minute warm ischemic hearts from asphyxiated canine non-heart-beating donors. J Heart Lung Transplant 2006; 25:339-44. [PMID: 16507429 DOI: 10.1016/j.healun.2005.09.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2005] [Revised: 05/13/2005] [Accepted: 09/11/2005] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Cardiac function of non-heart-beating donors (NHBDs) is uncertain due to severe myocardial damage. We developed an isolated myocardial perfusion system to resuscitate NHBD hearts and attempted to predict functional recovery of 60-minute warm ischemic hearts by analyzing systolic and diastolic functions. METHODS Hypoxic cardiac arrest was induced in 8 mongrel dogs without any pre-treatments. After 60-minute ischemia, intracoronary microthrombi were flushed out by retrograde blood cardiopledia with tissue-type plasminogen activator. Coronary arteries were initially perfused from the aortic root with tepid hyperkalemic blood (20 mmol/liter) at low pressure (20 mm Hg) for the first 60 minutes and then with normothermic blood for the next 60 minutes. After 120 minutes of reperfusion, pre-load was increased for ejection against an after-load of 80 mm Hg. Pressure-volume loops were recorded to obtain the end-systolic pressure-volume relationship (ESPVR) and end-diastolic pressure-volume relationship (EDPVR). Stroke volume at a given pre-load was calculated from averaged ESPVR, EDPVR and after-load identical to an averaged baseline value. The Frank-Starling relationship was obtained and cardiac status was classified according to Forrester's hemodynamic sub-set. RESULTS End-systolic elastance decreased significantly to about 60% of baseline and the time constant of isovolumic relaxation was prolonged significantly by about 20%. Cardiac index was decreased to about 50% and cardiac status was classified in the Forrester III or IV sub-set. CONCLUSIONS The extent of functional recovery of NHBD hearts is predictable by cardiac output. Although 120 minutes of recovery time may be short for 60-minute ischemic damage, this system may be feasible to predict post-transplant cardiac function before transplantation.
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Affiliation(s)
- Masanori Hirota
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan.
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Koike N, Takeyoshi I, Ohki S, Tsutsumi H, Matsumoto K, Morishita Y. The effect of short-term coronary perfusion using a perfusion apparatus on canine heart transplantation from non-heart-beating donors. J Heart Lung Transplant 2003; 22:810-7. [PMID: 12873550 DOI: 10.1016/s1053-2498(02)00650-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND We investigated the effects of briefly perfusing hearts from non-heart-beating donors (NHBDs) with a Celsior solution before cardiac transplantation. METHODS Donor hearts were left in situ for 20 minutes after cardiac arrest was induced by rapid exsanguination. Twelve donor-recipient pairs of mongrel dogs were divided into 2 groups, the simple immersion (SI, n = 6) group and the coronary perfusion (CP, n = 6) group. Both groups underwent coronary flushing with Celsior, after which hearts from the SI group were stored using simple immersion for 4 hours and hearts from the CP group underwent 1 hour of further perfusion followed by storage for 3 hours. Orthotopic transplantation was then performed. We measured cardiac output, end-systolic maximal elastance (E(max)), left ventricular pressure, and rate pressure product 1 and 2 hours after weaning from cardiopulmonary bypass (CPB). Two hours after weaning from CPB, the hearts were harvested for histopathologic study and to determine the percentage of water content. RESULTS The cardiac output (CO) recovery rate was significantly higher in the CP group than in the SI Group 1 hour after weaning from CPB (p < 0.05). The CO recovery rate, E(max), and rate pressure product were significantly higher and the percentage of water content was significantly lower in the CP group than in the SI Group 2 hours after weaning from CPB (p < 0.05). Histopathologic damage was more severe in the SI group. CONCLUSIONS The results of this study suggest that short-term coronary perfusion with a Celsior solution may be useful for heart transplantation from NHBDs.
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Affiliation(s)
- Norimasa Koike
- Second Department of Surgery, Gunma University School of Medicine, Maebashi, Gunma, Japan
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Mohri M, Suehiro K, Yamamoto S, Yamaguchi H, Ishino K, Sano S. Nicorandil ameliorates posttransplant dysfunction in cardiac allografts harvested from non-heart-beating donors. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2002; 50:430-4. [PMID: 12428383 DOI: 10.1007/bf02913177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Warm ischemia is a major cause of cardiac allograft dysfunction in non-heart-beating donors (NHBDs). We evaluated the cardioprotective effects of nicorandil, an adenosine triphosphate-sensitive potassium channel opener, on the early posttransplant left ventricular (LV) function of hearts harvested from asphyxiated canine NHBDs. METHODS Hypoxic cardiac arrest was induced in 12 donor dogs. In 6, nicorandil was administered intravenously at 100 micrograms/kg + 25 micrograms/kg/min after respiratory arrest and hearts were preserved with nicorandil-supplemented cardioplegic solution (nicorandil group). The remaining 6 did not receive nicorandil at any time during the experiment (control group). Hearts were orthotopically transplanted after a mean myocardial ischemic time of 4 hours. RESULTS All 12 recipients were weaned from cardiopulmonary bypass without inotropic support. In the control group, posttransplant cardiac indices and left ventricular end-systolic pressure (LVESP) decreased significantly, while LV max-dP/dt and Tau increased over pretransplant values. No differences were seen in parameters between pretransplant and posttransplant values in the nicorandil group. Posttransplant cardiac indices, LVESP, and LV max + dP/dt were higher in the nicorandil group than in controls, while posttransplant LV max-dP/dt in the nicorandil group was lower. CONCLUSIONS Our results indicate that pretreatment with nicorandil during hypoxic perfusion before cardiac arrest and subsequent preservation with nicorandil-supplemented cardioplegia ameliorates early posttransplant LV dysfunction of hearts harvested from asphyxiated NHBDs.
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Affiliation(s)
- Makoto Mohri
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, 2-5-1 Shikato-cho, Okayama, 700-8558, Japan
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