Effect of temperature during potassium arrest on myocardial metabolism and function

Outcomes in Heart Transplant Recipients by Bridge to Transplant Strategy When Using the SherpaPak Cardiac Transport System

The last several years have seen a rise in use of mechanical circulatory support (MCS) to bridge heart transplant recipients. A controlled hypothermic organ preservation system, the SherpaPak Cardiac Transport System (SCTS), was introduced in 2018 and has grown in utilization with reports of improved posttransplant outcomes. The Global Utilization And Registry Database for Improved heArt preservatioN (GUARDIAN)-Heart registry is an international, multicenter registry assessing outcomes after transplant using the SCTS. This analysis examines outcomes in recipients bridged with various MCS devices in the GUARDIAN-Heart Registry. A total of 422 recipients with donor hearts transported using SCTS were included and identified. Durable ventricular assist devices (VADs) were used exclusively in 179 recipients, temporary VADs or intra-aortic balloon pump (IABP) in 197, and extracorporeal membrane oxygenation (ECMO) in 14 recipients. Average ischemic times were over 3.5 hours in all cohorts. Severe primary graft dysfunction (PGD) posttransplant increased across groups (4.5% VAD, 5.1% temporary support, 21.4% ECMO), whereas intensive care unit (ICU) length of stay (18.2 days) and total hospital stay (39.4 days) was longer in the ECMO cohort than the VAD and IABP groups. A comparison of outcomes of MCS bridging in SCTS versus traditional ice revealed significantly lower rates of both moderate/severe right ventricular (RV) dysfunction and severe PGD in the SCTS cohort; however, upon propensity matching only the reductions in moderate/severe RV dysfunction were statistically significant. Use of SCTS in transplant recipients with various bridging strategies results in excellent outcomes.

Recipient Outcomes With Extended Criteria Donors Using Advanced Heart Preservation: An Analysis of the GUARDIAN-Heart Registry

BACKGROUND

The prevalence of end-stage heart failure and patients who could benefit from heart transplantation requires an expansion of the donor pool, relying on the transplant community to continually re-evaluate and expand the use of extended criteria donor organs. Introduction of new technologies such as the Paragonix SherpaPak Cardiac Transport System aids in this shift. We seek to analyze the impact of the SherpaPak system on recipient outcomes who receive extended criteria organs in the GUARDIAN-Heart Registry.

METHODS

Between October 2015 and December 2022, 1,113 adults from 15 US centers receiving donor hearts utilizing either SherpaPak (n = 560) or conventional ice storage (ice, n = 453) were analyzed from the GUARDIAN-Heart Registry using summary statistics. A previously published set of criteria was used to identify extended criteria donors, which included 193 SherpaPak and 137 ice.

RESULTS

There were a few baseline differences among recipients in the 2 cohorts; most notably, IMPACT scores, distance traveled, and total ischemic time were significantly greater in SherpaPak, and significantly more donor hearts in the SherpaPak cohort had >4 hours total ischemia time. Posttransplant mechanical circulatory support utilization (SherpaPak 22.3% vs ice 35.0%, p = 0.012) and new extracorporeal membrane oxygenation/ventricular assist device (SherpaPak 7.8% vs ice 15.3%, p = 0.033) was significantly reduced, and the rate of severe primary graft dysfunction (SherpaPak 6.2% vs ice 13.9%, p = 0.022) was significantly reduced by over 50% in hearts preserved using SherpaPak. One-year survival between cohorts was similar (SherpaPak 92.9% vs ice 89.6%, p = 0.27).

CONCLUSIONS

This subgroup analysis demonstrates that SherpaPak can be safely used to utilize extended criteria donors with low severe PGD rates.

Adenosine prevents activation of transcription factor NF-kappa B and enhances activator protein-1 binding activity in ischemic rat heart

BACKGROUND

Adenosine prevents myocardial TNF-alpha production induced by ischemia/reperfusion, but the mechanisms are poorly understood. Transcription factors NF-kappa B and AP-1 have been implicated in the regulation of a variety of inducible gene expressions in response to oxidative stress and cellular defense. The effects of adenosine on NF-kappa B and AP-1 activation have not been clearly defined. This study demonstrated differential effects of adenosine on NF-kappa B and AP-1 nuclear binding activity in ischemic myocardium.

METHODS

Isolated working rat hearts were subjected to 0, 1, 2, 3, 4, 5, 7.5, 10, 15, and 30 minutes of ischemia, with 4 to 6 hearts for each time point with and without adenosine (100 mumol/L). NF-kappa B and AP-1 binding activity in the nucleus were analyzed by electrophoretic mobility shift assay (EMSA). I kappa B alpha levels in the cytoplasm were measured by Western blot analysis. TNF-alpha mRNA levels were determined by RT-PCR.

RESULTS

NF-kappa B binding activity in the nucleus significantly increased after 4 minutes of ischemia and remained to 30 minutes. The levels of I kappa B alpha protein in the cytoplasm markedly decreased after 4, 5, 7.5, and 10 minutes of ischemia. TNF-alpha mRNA levels peaked after 10 minutes of ischemia. AP-1 DNA binding activity was induced and persisted during all ischemic periods. Adenosine significantly inhibited NK-kappa B binding activity in the nucleus, markedly prevented the loss of I kappa B alpha proteins from the cytoplasm, and concomitantly down-regulated TNF-alpha mRNA expression, but enhanced AP-1 binding activity in the nucleus of ischemic myocardium.

CONCLUSIONS

Adenosine modulation of NF-kappa B activation may be the cellular molecular mechanism of down-regulation of TNF-alpha mRNA expression. The cardioprotective properties of adenosine may be involved in the differential modulation of NF-kappa B and AP-1 activation during myocardial ischemia.

Early activation of transcription factor NF-kappaB during ischemia in perfused rat heart

The transcription factor nuclear factor kappaB (NF-kappaB) regulates multiple immediate-early gene expressions involved in immune and inflammatory responses and cellular defenses. Ischemia-reperfusion induces many immediate-early gene expressions, but little is known about the NF-kappaB activation in myocardium during ischemia and reperfusion. This study demonstrated that ischemia alone rapidly induced NF-kappaB activation in the myocardium of isolated working rat hearts. Electrophoretic mobility shift assay showed that NF-kappaB binding activity significantly increased in the nucleus after 5 min of ischemia and remained elevated for up to 30 min. Western blot analysis suggested that the levels of inhibitory IkappaBalpha protein in the cytoplasm became markedly decreased at 4, 5, 7.5, and 10 min of ischemia but were gradually restored following 10 min of ischemia. Reduction of IkappaBalpha protein in the cytoplasm by ischemia resulted in NF-kappaB translocation to the nucleus. Northern blot hybridization showed that IkappaBalpha mRNA levels were not significantly elevated during myocardial ischemia. Pyrrolidine dithiocarbamate, an antioxidant, significantly inhibited the loss of IkappaBalpha protein from the cytoplasm and prevented NF-kappaB binding activity in the nucleus. Reperfusion following short periods of ischemia augmented NF-kappaB binding activity in the nucleus induced by ischemia. The results suggest that early activation of NF-kappaB induced by ischemia in the myocardium could be a signal mechanism for controlling and regulating immediate-early gene expression during ischemia-reperfusion.

The influence of temperature on metabolic and cellular protection of the heart during long-term ischemia: a study using P-31 magnetic resonance spectroscopy and biochemical analyses

We have compared the influence of two different cold temperatures (below 10 degreesC) for cardiac ischemia by measuring a large variety of hemodynamic and metabolic parameters during ischemia and reflow. Isolated isovolumic rat hearts were arrested with a preservation solution which was developed in our laboratory and then submitted to 5 h of cold storage (4 degreesC, group I; and 7.5 degreesC, group II) in the same solution. After an additional period of 50 min of ischemia at 15 degreesC with intermittent cardioplegic infusion, hearts were reperfused for 60 min at 37 degreesC. Function was assessed during the control period and reflow. High-energy phosphates and intracellular pH were followed by 31P magnetic resonance spectroscopy. Analyses of metabolites and enzymes were performed by biochemical assays and HPLC in coronary effluents and in freeze-clamped hearts to assess cellular integrity. The energetic pool was better preserved at 4 degreesC during ischemia (ATP at the end of 4 degreesC ischemia, 59 +/- 7% in group I vs 31 +/- 5% in group II, P < 0.01) and reflow (P < 0.05) but membrane protection was higher when increasing the temperature to 7.5 degreesC (reduction of creatine kinase leakage, 89 +/- 16 IU/min in group I vs 51 +/- 5 IU/min in group II, P < 0.05). As a result, functional recovery, represented by the rate pressure product, was higher in hearts preserved at 7.5 degreesC (52 +/- 6% recovery in group I vs 77 +/- 7% in group II at the end of reflow, P < 0.05). Altogether, cold storage at 7.5 degreesC provides a better protection than storage at 4 degreesC.

Comparisons of methods of myocardial hypothermia for cardiac transplantation

BACKGROUND

Myocardial hypothermia of less than 10 degrees C is an essential component of preservation of donor hearts before implantation. Here we report temperature changes and comparison of methods for maintenance of myocardial hypothermia during implantation.

METHODS

Twenty patients were prospectively randomized into two equal groups. In one cohort myocardial hypothermia was maintained by the "Stanford method" of continuous lavage of the pericardium and left atrium with refrigerated saline solution. In the other a cooling jacket was used without saline lavage. Temperatures at multiple sites were measured at 30-second intervals from initiation of cardiac suturing until aortic cross-clamp removal. Comparisons were made between groups at each temperature site.

RESULTS

The cooling jacket group temperatures were significantly lower at the left ventricular epicardium and endocardium than those of the Stanford method group.

CONCLUSIONS

During cardiac implantation maintenance of myocardial hypothermia with a cooling jacket resulted in significantly deeper and more consistent hypothermia of the left ventricle than pericardial and left atrial lavage with refrigerated saline solution. Blood loss from aspirated saline lavage and perfusate dilution by the saline solution were eliminated.

Ischemia affects cardiac proteins in healthy animals less severely than in human patients

BACKGROUND

Recently, our group showed that in human hearts proteins are extremely sensitive to ischemic injury. The purpose of this investigation was to evaluate the effects of ischemia on contractile and cytoskeletal proteins in rabbit and pig hearts and to compare these findings with those obtained in humans.

METHODS

Rabbit hearts were arrested by perfusion with Euro-Collins solution at different temperatures. Hearts perfused with buffer served as controls. Tissue samples were incubated for varying time intervals and processed for immunohistochemistry and electron microscopy. Porcine hearts were treated in the same manner. Changes in the localization of myosin, desmin, and tropomyosin antibodies were evaluated and the degree of ischemic injury was determined by electron microscopy.

RESULTS

Healthy animal hearts tolerate ischemia better than human hearts. Cardiac proteins are more sensitive to ischemia than the ultrastructural cellular organelles. Temperatures as low as 0 degree C produce more cell damage than 4 degrees C and should therefore be avoided. The Euro-Collins solution protects the myocardium better than buffer.

CONCLUSIONS

We conclude that healthy animal hearts are more resistant to ischemia than diseased human hearts and that results from experimental studies should be interpreted with caution with regard to the human situation.

The effects of a temperature below 15 degrees C on the myocardial calcium and ultrastructure in donor heart preservation in a canine model

The effects of 6-h hypothermic cardioplegic arrest on myocardial biochemical, morphologic, and functional recovery were investigated in two groups of dogs. Group 1 (n = 6) was subjected to hypothermia of 15 degrees C and group 2 (n = 6) was subjected hypothermia of 5 degrees C. Although the myocardial calcium (Ca) concentration was significantly higher at the end of reperfusion in group 2 compared to group 1, the MB-fraction of creatine kinase, mitochondrial aspartate aminotransferase, recovery of left ventricular systolic function, and mitochondrial morphologic integrity were better in group 2 than in group 1. These findings suggest that hypothermia of 5 degrees C in 6-h cardioplegia is not necessarily coupled with interference in myocardial contractility, despite the Ca overload that occurs during reperfusion.

Isolated biventricular working rat heart preparation

The isolated perfused heart from small animals has been used extensively for hemodynamic and metabolic studies. The left working heart preparation proved superior to the Langendorff model for functional evaluations but has not allowed study of right heart function. A simple and inexpensive biventricular working heart preparation has been developed by modifying the left working rat heart model. Under general anesthesia the heart was removed surgically leaving sufficient vessels attached to it. Cannulation of the aorta, left atrium, right atrium, and pulmonary artery was completed in 10 minutes. A pressurized compliance chamber allowed rapid and reliable regulation of aortic impedance. For the 7 hearts that were subjected to 3-hour biventricular perfusion (their end points expressed as percent of their initial values), the aortic output (95% +/- 3%), pulmonary flow (88% +/- 9%), mean aortic pressure (109% +/- 5%), mean pulmonary pressure (100% +/- 2%), heart rate (106% +/- 8%), myocardial adenosine triphosphate level (85% +/- 8%), and creatine phosphate level (89% +/- 4%) were all maintained at physiologic levels. For the 11 hearts that were converted from left working heart preparation to biventricular working mode, significant improvement in stroke volume, aortic and cardiac output, and pressure development were observed. Experimental results indicate that the biventricular working model for isolated perfused rat hearts is superior to the left working preparation for studying the function of the total heart. Further study of the biventricular perfused working rat heart appears warranted.

Preliminary evaluation of cocarboxylase on myocardial protection of the rat heart

The presence of cocarboxylase (CC) is essential for the oxidation of pyruvate to acetylcoenzyme A (acetyl-CoA) and its subsequent degradation by means of the Krebs cycle. We compared the effects of various concentrations of CC in a cardioplegic solution on the survival and hemodynamic and metabolic recovery of 23 isolated, working rat hearts subjected to 60 minutes of hypothermic (23 degrees C) ischemic arrest. Group 1 (N = 6) consisted of hearts infused with the basic cardioplegic solution (Tyers' solution with glucose), to which no CC was added. In group 2 (N = 6) CC was added at 0.1 ml/L to the cardioplegic solution. In group 3 (N = 5) CC was added at 1 ml/L, and in group 4 (N = 6) CC was added at 10 ml/L. The cardioplegic infusions were performed at a pressure of 40 mm Hg for 2 minutes just before arrest; 30 minutes later they were performed again for 1 minute. Only two hearts (33.3%) recovered in group 1 whereas five recovered in group 2, five (100%) in group 3, and five (83.3%) in group 4. The recovery of hemodynamic performance as a percentage of preischemic control values showed marked improvement in the CC groups, especially group 3, when compared with group 1. The metabolic variables in the CC groups were also markedly improved, with significantly (p less than .05) decreased levels of tissue lactate and increased levels of creatine phosphate compared with those in group 1.(ABSTRACT TRUNCATED AT 250 WORDS)

Recent advances in cardiopulmonary bypass and the clinical application of myocardial protection

Basic scientific research has provided the impetus to develop cardioplegic solutions that offer excellent myocardial preservation. Future research will continue to develop methods for better delivery of cardioplegia to all myocardial regions. In addition, earlier detection of evolving ischemic damage during aortic cross-clamping might provide a basis for earlier intervention to reverse developing myocardial injury. At the present time, the cardiac surgeon has many cardioplegic solutions and delivery systems from which to choose. Only by understanding the principles involved in myocardial preservation will the surgeon be able to develop a system that will work best in his or her clinical practice.

Concepts and techniques of myocardial protection for adult open heart surgery

Discussions of myocardial protection are often limited to the subject of cardioplegia. However, numerous aspects of operative and perioperative care are of comparable importance. This article outlines the broad topic of myocardial protection, provides strategies for its practical implementation, and reports the author's personal results.

Interactions between pharmacological cardioplegia and hypothermia for intraoperative myocardial protection

Cold cardioplegia is currently the method of choice for providing myocardial protection during open-heart surgical procedures. Two components of protection, perfusion cooling and pharmacological cardiac arrest, were investigated in the guinea pig heart-lung model. The effects of two cardioplegic solutions, the University of Alabama Hospital solution and the St. Thomas' Hospital solution, and a control perfusate were compared. The results confirmed the efficacy of hypothermia as a protective agent and the additional protection afforded by pharmacological cardioplegia. Infusion temperature critically influenced the cardioprotective action of the Alabama solution: Striking protection was afforded only under hypothermic conditions, whereas myocardial damage was exacerbated by the infusion at 37 degrees C. The St. Thomas' Hospital solution provided substantial protection independent of infusion temperature. Thus, the safety margin of the Alabama solution was narrower than that of the St. Thomas' solution. It is suggested that the difference between the two cardioplegic solutions partially depends on their coronary vasoactivity, since the administration of the Alabama solution at 37 degrees C increased coronary perfusion pressure. It would seem worthwhile to use a temperature-independent cardioplegic solution devoid of coronary vasoconstricting action.

Metabolic and functional effects of carbohydrate substrate with single-dose and multiple-dose potassium cardioplegia

The isolated working rat heart model of ischemic arrest was used to determine if the addition of carbohydrate substrate to our cardioplegic solution enhanced metabolic and functional myocardial protection. A single-dose cardioplegia technique, as used in earlier studies that showed glucose to have a harmful effect, and a multidose technique similar to that used clinically were studied and compared. Because recent data suggest that fructose-1,6-diphosphate(FDP) may have a protective effect with ischemia, this substrate was also tested and compared to glucose and fructose. In this model, single-dose cardioplegia resulted in poor protection from ischemic injury in all study groups. There was marked improvement in myocardial protection with multidose cardioplegia, and further substantial protection of myocardial function, high-energy phosphate levels, and glycogen stores when carbohydrate substrate was added to the arrest solution. The solution with a higher concentration of glucose (0.5%) provided the best overall metabolic and functional recovery and was clearly superior to fructose and FDP, both of which had about the same protective effect. Improved protection with carbohydrate substrate was accompanied by evidence of substantial increase in glycolytic flux, supporting the idea that increased anaerobic glycolysis can help protect the ischemic myocardium when intermittent reinfusion of cardioplegic solution is done.

Effect of venting on myocardial protection by hypothermic cardioplegic arrest

Myocardial rewarming between cardioplegic (CP) infusions is in part attributable to blood circulating through the heart from collateral channels. This experiment was performed to determine if the type of left ventricular (LV) venting affects myocardial temperature (temp) or alters myocardial protection. Twelve dogs underwent cardiopulmonary bypass (CPB) at 37 degrees C and were subjected to 100 min of cardioplegic arrest by intermittent coronary infusion of 300 ml 0-4 degrees C CP solution. Arterial, central venous, left atrial, and LV pressures; cardiac output; systemic, septal (S), right ventricular (RV), and LV temp; myocardial ATP and glycogen were measured; LV pressure/volume curves and LV dp/dt were calculated. Group A (6 dogs) had an LV vent during CPB, and Group B (6 dogs) had the aorta vented via the CP line. CP infusion lowered LV temp to 8 degrees C in Group A vs 13 degrees C in Group B (P less than 0.000002); S temp was lowered to 7 degrees C in Group A vs 11 C in Group B (P less than 0.00007); and RV temp was lowered to 16 degrees C in Groups A and B. Ten minutes after CP, LV and S temp increased to 20-21 degrees C in Groups A and B, and RV temp to 24-25 degrees C in Groups A and B. Twenty minutes after CP all temperatures were the same. Hemodynamics and myocardial metabolic studies were similar in the two groups.

CONCLUSIONS

Hearts vented via the LV cooled to a lower temperature vs those vented via the aorta. Venting did not affect myocardial rewarming, myocardial metabolites, or ventricular function.