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DiChiacchio L, Goodwin ML, Kagawa H, Griffiths E, Nickel IC, Stehlik J, Selzman CH. Heart Transplant and Donors After Circulatory Death: A Clinical-Preclinical Systematic Review. J Surg Res 2023; 292:222-233. [PMID: 37657140 DOI: 10.1016/j.jss.2023.07.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 09/03/2023]
Abstract
INTRODUCTION Heart transplantation is the treatment of choice for end-stage heart failure. There is a mismatch between the number of donor hearts available and the number of patients awaiting transplantation. Expanding the donor pool is critically important. The use of hearts donated following circulatory death is one approach to increasing the number of available donor hearts. MATERIALS AND METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines utilizing Pubmed/MEDLINE and Embase. Articles including adult human studies and preclinical animal studies of heart transplantation following donation after circulatory death were included. Studies of pediatric populations or including organs other than heart were excluded. RESULTS Clinical experience and preclinical studies are reviewed. Clinical experience with direct procurement, normothermic regional perfusion, and machine perfusion are included. Preclinical studies addressing organ function assessment and enhancement of performance of marginal organs through preischemic, procurement, preservation, and reperfusion maneuvers are included. Articles addressing the ethical considerations of thoracic transplantation following circulatory death are also reviewed. CONCLUSIONS Heart transplantation utilizing organs procured following circulatory death is a promising method to increase the donor pool and offer life-saving transplantation to patients on the waitlist living with end-stage heart failure. There is robust ongoing preclinical and clinical research to optimize this technique and improve organ yield. There are also ongoing ethical considerations that must be addressed by consensus before wide adoption of this approach.
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Affiliation(s)
- Laura DiChiacchio
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Matthew L Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Hiroshi Kagawa
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Eric Griffiths
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Ian C Nickel
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiology, University of Utah, Salt Lake City, Utah
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah.
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2
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Schroder JN, Scheuer S, Catarino P, Caplan A, Silvestry SC, Jeevanandam V, Large S, Shah A, MacDonald P, Slaughter MS, Naka Y, Milano CA. The American Association for Thoracic Surgery 2023 Expert Consensus Document: Adult cardiac transplantation utilizing donors after circulatory death. J Thorac Cardiovasc Surg 2023; 166:856-869.e5. [PMID: 37318399 DOI: 10.1016/j.jtcvs.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/10/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Jacob N Schroder
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Sarah Scheuer
- Department of Surgery, St Vincent's Hospital, Sydney, Australia
| | | | - Arthur Caplan
- Department of Bioethics, New York University Grossman School of Medicine, New York, NY
| | | | | | | | - Ashish Shah
- Department of Cardiothoracic Surgery, Vanderbilt University, Nashville, Tenn
| | - Peter MacDonald
- Department of Surgery, St Vincent's Hospital, Sydney, Australia
| | | | - Yoshifumi Naka
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY
| | - Carmelo A Milano
- Department of Surgery, Duke University Medical Center, Durham, NC.
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3
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Pradegan N, Gallo M, Fabozzo A, Toscano G, Tarzia V, Gerosa G. Nonischemic Donor Heart Preservation: New Milestone in Heart Transplantation History. ASAIO J 2023; 69:725-733. [PMID: 37319037 DOI: 10.1097/mat.0000000000002001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
Heart transplantation is considered the gold standard for the treatment of advanced end-stage heart failure. However, standard donors after brain death are decreasing, whereas patients on the heart transplant waitlist are constantly rising. The introduction of the ex vivo machine perfusion device has been a turning point; in fact, these systems are able to significantly reduce ischemic times and have a potential effect on ischemia-related damage reduction. From a clinical standpoint, these machines show emerging results in terms of heart donor pool expansion, making marginal donors and donor grafts after circulatory death suitable for donation. This article aims to review mechanisms and preclinical and clinical outcomes of currently available ex vivo perfusion systems, and to explore the future fields of application of these technologies.
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Affiliation(s)
- Nicola Pradegan
- From the Cardiac Surgery Unit, Heart Transplantation Program, Cardiac, Thoracic, Vascular Sciences and Public Health Department, Padova University Hospital, Padova, Italy
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Kaffka Genaamd Dengler SE, Mishra M, van Tuijl S, de Jager SCA, Sluijter JPG, Doevendans PA, van der Kaaij NP. Cold Oxygenated Machine Perfusion Improves Functional Survival of Slaughterhouse Porcine Hearts. ASAIO J 2023; 69:774-781. [PMID: 37146423 DOI: 10.1097/mat.0000000000001955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
The aim of our study was to explore the effect of cold oxygenated machine perfusion in slaughterhouse porcine hearts on functional myocardial survival compared to static cold storage (SCS). Seventeen hearts were harvested from Dutch Landrace Hybrid pigs, which were sacrificed for human consumption and randomly assigned to the 4 hours SCS group (N = 10) or the 4 hours cold oxygenated machine perfusion group (N = 7). Hearts were perfused with a homemade Heart Solution with a perfusion pressure of 20-25 mm Hg to achieve a coronary flow between 100 and 200 ml/minute. After 4 hours of preservation, all hearts were functionally assessed during 4 hours on a normothermic, oxygenated diluted whole blood (1:2) loaded heart model. Survival was defined by a cardiac output above 3 L with a mean aortic pressure above 60 mm Hg. Survival was significantly better in the cold oxygenated machine perfusion group, where 100% of the hearts reached the 4 hours end-point, as compared with 30% in the SCS group ( p = 0.006). Interestingly, warm ischemic time was inversely related to survival in the SCS group with a correlation coefficient of -0.754 ( p = 0.012). Cold oxygenated machine perfusion improves survival of the slaughterhouse porcine heart.
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Affiliation(s)
| | - Mudit Mishra
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Laboratory of Experimental Cardiology, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | | | - Saskia C A de Jager
- Laboratory of Experimental Cardiology, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Joost P G Sluijter
- Laboratory of Experimental Cardiology, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - Niels P van der Kaaij
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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5
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Mastrobuoni S, Johanns M, Vergauwen M, Beaurin G, Rider M, Gianello P, Poncelet A, Van Caenegem O. Comparison of Different Ex-Vivo Preservation Strategies on Cardiac Metabolism in an Animal Model of Donation after Circulatory Death. J Clin Med 2023; 12:jcm12103569. [PMID: 37240675 DOI: 10.3390/jcm12103569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Transplantation of heart following donation after circulatory death (DCD) was recently introduced into clinical practice. Ex vivo reperfusion following DCD and retrieval is deemed necessary in order to evaluate the recovery of cardiac viability after the period of warm ischemia. We tested the effect of four different temperatures (4 °C-18 °C-25 °C-35 °C) on cardiac metabolism during 3-h ex vivo reperfusion in a porcine model of DCD heart. We observed a steep fall in high-energy phosphate (ATP) concentrations in the myocardial tissue at the end of the warm ischemic time and only limited regeneration during reperfusion. Lactate concentration in the perfusate increased rapidly during the first hour of reperfusion and slowly decreased afterward. However, the temperature of the solution does not seem to have an effect on either ATP or lactate concentration. Furthermore, all cardiac allografts showed a significant weight increase due to cardiac edema, regardless of the temperature.
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Affiliation(s)
- Stefano Mastrobuoni
- Cardiovascular and Thoracic Surgery Department, Saint-Luc's Hospital, Catholic University of Louvain, 1200 Brussels, Belgium
- Pole de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique (IREC), Catholic University of Louvain, 1200 Brussels, Belgium
| | - Manuel Johanns
- Pole de Biochimie et Recherche Metabolique, Institue de Duve, Catholic University of Louvain, 1200 Brussels, Belgium
| | - Martial Vergauwen
- Pole de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique (IREC), Catholic University of Louvain, 1200 Brussels, Belgium
| | - Gwen Beaurin
- Pole de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique (IREC), Catholic University of Louvain, 1200 Brussels, Belgium
| | - Mark Rider
- Pole de Biochimie et Recherche Metabolique, Institue de Duve, Catholic University of Louvain, 1200 Brussels, Belgium
| | - Pierre Gianello
- Pole de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique (IREC), Catholic University of Louvain, 1200 Brussels, Belgium
| | - Alain Poncelet
- Cardiovascular and Thoracic Surgery Department, Saint-Luc's Hospital, Catholic University of Louvain, 1200 Brussels, Belgium
- Pole de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique (IREC), Catholic University of Louvain, 1200 Brussels, Belgium
| | - Olivier Van Caenegem
- Pole de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique (IREC), Catholic University of Louvain, 1200 Brussels, Belgium
- Cardiac Intensive Care Unit, Saint-Luc's Hospital, Catholic University of Louvain, 1200 Brussels, Belgium
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6
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Hatami S, Conway J, Freed DH, Urschel S. Thoracic organ donation after circulatory determination of death. TRANSPLANTATION REPORTS 2023. [DOI: 10.1016/j.tpr.2022.100125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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7
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Normothermic Ex Situ Heart Perfusion With the Organ Care System for Cardiac Transplantation: A Meta-analysis. Transplantation 2022; 106:1745-1753. [PMID: 35618669 DOI: 10.1097/tp.0000000000004167] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Heart transplantation (HTx) is, at present, the most effective therapy for end-stage heart failure patients; however, the number of patients on the waiting list is rising globally, further increasing the gap between demand and supply of donors for HTx. First studies using the Organ Care System (OCS) for normothermic machine perfusion show promising results yet are limited in sample size. This article presents a meta-analysis of heart donation either after brain death (OCS-DBD) or circulatory death (OCS-DCD) on using OCS versus static cold storage used for HTx. METHODS A systematic literature search was performed for articles discussing the use of normothermic ex situ heart perfusion in adult patients. Thirty-day survival outcomes were pooled, and odds ratios were calculated using random-effects models. Long-term survival was visualized with Kaplan-Meier curves, hazard ratios were calculated and pooled using fixed-effects models, and secondary outcomes were analyzed. RESULTS A total of 12 studies were included, with 741 patients undergoing HTx, of which 260 with the OCS (173 DBD and 87 DCD). No differences were found between the 3 groups for early and late survival outcomes or for secondary outcomes. CONCLUSIONS OCS outcomes, for both DBD and DCD hearts, appeared similar as for static cold storage. Therefore, OCS is a safe and effective technique to enlarge the cardiac donor pool in both DBD and DCD, with additional benefits for long-distance transport and surgically complex procedures.
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8
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Machine Perfusion of Donor Hearts: The Next Major Advance in Cardiac Transplantation. Transplantation 2022; 106:1724-1725. [PMID: 35618667 DOI: 10.1097/tp.0000000000004168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hatami S, Qi X, White CW, Bozso SJ, Himmat S, Sergi C, Nagendran J, Chung HJ, Nobes DS, Freed DH. The Position of the Heart During Normothermic Ex Situ Heart Perfusion is an Important Factor in Preservation and Recovery of Myocardial Function. ASAIO J 2021; 67:1222-1231. [PMID: 33741785 DOI: 10.1097/mat.0000000000001386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Ex situ heart perfusion (ESHP) is being investigated as a method for the continuous preservation of the myocardium in a semiphysiologic state for subsequent transplantation. Most methods of ESHP position the isolated heart in a hanging (H) state, representing a considerable departure from the in vivo anatomical positioning of the heart and may negatively affect the functional preservation of the heart. In the current study, cardiac functional and metabolic parameters were assessed in healthy pig hearts, perfused for 12 hours, in either an H, or supported (S) position, either in nonworking mode (NWM) or working mode (WM). The cardiac function was best preserved in the S position hearts in WM (median 11 hour cardiac index (CI)/1 hour CI%: working mode perfusion in supported position = 94.77% versus nonworking mode perfusion in supported position = 62.80%, working mode perfusion in H position = 36.18%, nonworking mode perfusion in H position = 9.75%; p < 0.001). Delivery of pyruvate bolus significantly improved the function in S groups, however, only partially reversed myocardial dysfunction in the H heart groups. The hearts perfused ex situ in a semianatomical S position and in physiologic WM had better functional preservation and recovery than the H hearts in non-S position. Optimizing the positional support for the ex situ-perfused hearts may improve myocardial preservation during ESHP.
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Affiliation(s)
- Sanaz Hatami
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
| | - Xiao Qi
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
| | - Christopher W White
- Department of surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sabin J Bozso
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
| | - Sayed Himmat
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
| | - Consolato Sergi
- Department of Laboratory Medicine and Pathology, Faculty of Medicine, Canada
| | - Jayan Nagendran
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
- Canadian Donation and Transplantation Research Program, Canada
| | - Hyun-Joong Chung
- Department of Chemical and Materials Engineering Faculty of Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - David S Nobes
- Department of Mechanical Engineering, Faculty of Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Darren H Freed
- From the Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Transplant Institute, Edmonton, Alberta, Canada
- Canadian Donation and Transplantation Research Program, Canada
- Department of Physiology, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Department of Biomedical Engineering, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
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10
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van Suylen V, Vandendriessche K, Neyrinck A, Nijhuis F, van der Plaats A, Verbeken EK, Vermeersch P, Meyns B, Mariani MA, Rega F, Erasmus ME. Oxygenated machine perfusion at room temperature as an alternative for static cold storage in porcine donor hearts. Artif Organs 2021; 46:246-258. [PMID: 34633676 PMCID: PMC9298357 DOI: 10.1111/aor.14085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/15/2021] [Accepted: 10/05/2021] [Indexed: 01/06/2023]
Abstract
Background There is a continued interest in ex situ heart perfusion as an alternative strategy for donor heart preservation. We hypothesize that oxygenated machine perfusion of donor hearts at a temperature that avoids both normothermia and deep hypothermia offers adequate and safe preservation. Methods Cardioplegia‐arrested porcine donor hearts were randomly assigned to six hours of preservation using cold storage (CS, n = 5) or machine perfusion using an oxygenated acellular perfusate at 21°C (MP, n = 5). Subsequently, all grafts were evaluated using the Langendorff method for 120 min. Metabolic parameters and histology were analyzed. Systolic function was assessed by contractility and elastance. Diastolic function was assessed by lusitropy and stiffness. Results For both groups, in vivo baseline and post‐Langendorff biopsies were comparable, as were lactate difference and myocardial oxygen consumption. Injury markers gradually increased and were comparable. Significant weight gain was seen in MP (p = 0.008). Diastolic function was not impaired in MP, and lusitropy was superior from 30 min up to 90 min of reperfusion. Contractility was superior in MP during the first hour of evaluation. Conclusion We conclude that the initial functional outcome of MP‐preserved hearts was transiently superior compared to CS, with no histological injury post‐Langendorff. Our machine perfusion strategy could offer feasible and safe storage of hearts prior to transplantation. Future studies are warranted for further optimization.
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Affiliation(s)
- Vincent van Suylen
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Arne Neyrinck
- Laboratory of Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, Catholic University Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Erik K Verbeken
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Histopathology, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Vermeersch
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Filip Rega
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Michiel E Erasmus
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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11
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Arni S, Maeyashiki T, Opitz I, Inci I. Subnormothermic ex vivo lung perfusion attenuates ischemia reperfusion injury from donation after circulatory death donors. PLoS One 2021; 16:e0255155. [PMID: 34339443 PMCID: PMC8328332 DOI: 10.1371/journal.pone.0255155] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 07/10/2021] [Indexed: 01/28/2023] Open
Abstract
Use of normothermic ex vivo lung perfusion (EVLP) was adopted in clinical practice to assess the quality of marginal donor lungs. Subnormothermic perfusion temperatures are in use among other solid organs to improve biochemical, clinical and immunological parameters. In a rat EVLP model of donation after circulatory death (DCD) lung donors, we tested the effect of four subnormothermic EVLP temperatures that could further improve organ preservation. Warm ischemic time was of 2 hours. EVLP time was of 4 hours. Lung physiological data were recorded and metabolic parameters were assessed. Lung oxygenation at 21°C and 24°C were significantly improved whereas pulmonary vascular resistance and edema formation at 21°C EVLP were significantly worsened when compared to 37°C EVLP. The perfusate concentrations of potassium ions and lactate exiting the lungs with 28°C EVLP were significantly lower whereas sodium and chlorine ions with 32°C EVLP were significantly higher when compared to 37°C EVLP. Also compared to 37°C EVLP, the pro-inflammatory chemokines MIP2, MIP-1α, GRO-α, the cytokine IL-6 were significantly lower with 21°C, 24°C and 28°C EVLP, the IL-18 was significantly lower but only with 21°C EVLP and IL-1β was significantly lower at 21°C and 24°C EVLP. Compared to the 37°C EVLP, the lung tissue ATP content after 21°C, 24°C and 28°C EVLP were significantly higher, the carbonylated protein content after 28°C EVLP was significantly lower and we measured significantly higher myeloperoxidase activities in lung tissues with 21°C, 24°C and 32°C. The 28°C EVLP demonstrated acceptable physiological variables, significantly higher lung tissue ATP content and decreased tissue carbonylated proteins with reduced release of pro-inflammatory cytokines. In conclusion, the 28°C EVLP is a non inferior setting in comparison to the clinically approved 37°C EVLP and significantly improve biochemical, clinical and immunological parameters and may reduce I/R injuries of DCD lung donors.
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Affiliation(s)
- Stephan Arni
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Tatsuo Maeyashiki
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
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12
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Scheuer SE, Jansz PC, Macdonald PS. Heart transplantation following donation after circulatory death: Expanding the donor pool. J Heart Lung Transplant 2021; 40:882-889. [PMID: 33994229 DOI: 10.1016/j.healun.2021.03.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022] Open
Abstract
Heart transplantation from donation after circulatory death (DCD) donors is a rapidly expanding practice. In this review, we describe the history and challenges of DCD heart transplantation and overview the procurement protocols and methods of limiting ischemic injury, current outcomes, and future directions. There are now at least three protocols that permit resuscitation and viability assessment of the DCD heart either in situ or ex situ. While the retrieval protocol for hearts from DCD donors will depend on local regulations, the outcomes of DCD heart transplant recipients reported to date are excellent regardless of the retrieval protocol and are comparable to the outcomes of heart transplant recipients from donation after brain death (DBD) donors. In the two centers with the largest published experience, DCD heart transplantation now accounts for one third of their heart transplant activity. With international trends indicating that there is an increasing utilisation of the DCD pathway, it is expected that DCD donors will become a major source of heart donation worldwide.
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Affiliation(s)
- Sarah E Scheuer
- Cardiac Physiology & Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; Heart & Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Randwick, Australia
| | - Paul C Jansz
- Cardiac Physiology & Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; Heart & Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Randwick, Australia
| | - Peter S Macdonald
- Cardiac Physiology & Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; Heart & Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Randwick, Australia.
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13
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Wyss RK, Méndez Carmona N, Arnold M, Segiser A, Mueller M, Dutkowski P, Carrel TP, Longnus SL. Hypothermic, oxygenated perfusion (HOPE) provides cardioprotection via succinate oxidation prior to normothermic perfusion in a rat model of donation after circulatory death (DCD). Am J Transplant 2021; 21:1003-1011. [PMID: 32786170 DOI: 10.1111/ajt.16258] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 01/25/2023]
Abstract
In donation after circulatory death (DCD), cardiac grafts are subjected to warm ischemia in situ, prior to a brief period of cold, static storage (CSS) at procurement, and ex situ, normothermic, machine perfusion (NMP) for transport and graft evaluation. Cold ischemia and normothermic reoxygenation during NMP could aggravate graft injury through continued accumulation and oxidation, respectively, of mitochondrial succinate, and the resultant oxidative stress. We hypothesized that replacing CSS with hypothermic, oxygenated perfusion (HOPE) could provide cardioprotection by reducing cardiac succinate levels before NMP. DCD was simulated in male Wistar rats. Following 21 minutes in situ ischemia, explanted hearts underwent 30 minutes hypothermic storage with 1 of the following: (1) CSS, (2) HOPE, (3) hypothermic deoxygenated perfusion (HNPE), or (4) HOPE + AA5 (succinate dehydrogenase inhibitor) followed by normothermic reperfusion to measure cardiac and metabolic recovery. After hypothermic storage, tissue ATP/ADP levels were higher and succinate concentration was lower in HOPE vs CSS, HNPE, and HOPE + AA5 hearts. After 60 minutes reperfusion, cardiac function was increased and cellular injury was decreased in HOPE compared with CSS, HNPE, and HOPE + AA5 hearts. HOPE provides improved cardioprotection via succinate oxidation prior to normothermic reperfusion compared with CSS, and therefore is a promising strategy for preservation of cardiac grafts obtained with DCD.
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Affiliation(s)
- Rahel K Wyss
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Natalia Méndez Carmona
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Maria Arnold
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Adrian Segiser
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Matteo Mueller
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Sarah L Longnus
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
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14
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Bona M, Wyss RK, Arnold M, Méndez-Carmona N, Sanz MN, Günsch D, Barile L, Carrel TP, Longnus SL. Cardiac Graft Assessment in the Era of Machine Perfusion: Current and Future Biomarkers. J Am Heart Assoc 2021; 10:e018966. [PMID: 33522248 PMCID: PMC7955334 DOI: 10.1161/jaha.120.018966] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Heart transplantation remains the treatment of reference for patients experiencing end‐stage heart failure; unfortunately, graft availability through conventional donation after brain death is insufficient to meet the demand. Use of extended‐criteria donors or donation after circulatory death has emerged to increase organ availability; however, clinical protocols require optimization to limit or prevent damage in hearts possessing greater susceptibility to injury than conventional grafts. The emergence of cardiac ex situ machine perfusion not only facilitates the use of extended‐criteria donor and donation after circulatory death hearts through the avoidance of potentially damaging ischemia during graft storage and transport, it also opens the door to multiple opportunities for more sensitive monitoring of graft quality. With this review, we aim to bring together the current knowledge of biomarkers that hold particular promise for cardiac graft evaluation to improve precision and reliability in the identification of hearts for transplantation, thereby facilitating the safe increase in graft availability. Information about the utility of potential biomarkers was categorized into 5 themes: (1) functional, (2) metabolic, (3) hormone/prohormone, (4) cellular damage/death, and (5) inflammatory markers. Several promising biomarkers are identified, and recommendations for potential improvements to current clinical protocols are provided.
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Affiliation(s)
- Martina Bona
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Rahel K Wyss
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Maria Arnold
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Natalia Méndez-Carmona
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Maria N Sanz
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Dominik Günsch
- Department of Anesthesiology and Pain Medicine/Institute for Diagnostic, Interventional and Paediatric Radiology Bern University HospitalInselspitalUniversity of Bern Switzerland
| | - Lucio Barile
- Laboratory for Cardiovascular Theranostics Cardiocentro Ticino Foundation and Faculty of Biomedical Sciences Università Svizzera Italiana Lugano Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Sarah L Longnus
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
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15
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Myocardial Substrate Oxidation and Tricarboxylic Acid Cycle Intermediates During Hypothermic Machine Perfusion. J Surg Res 2020; 259:242-252. [PMID: 33250204 DOI: 10.1016/j.jss.2020.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 09/15/2020] [Accepted: 09/22/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The optimal substrate for hypothermic machine perfusion preservation of donor hearts is unknown. Fatty acids, acetate, and ketones are preferred substrates of the heart during normothermic perfusion, but cannot replete the tricarboxylic acid (TCA) cycle directly. Propionate, an anaplerotic substrate, can replenish TCA cycle intermediates and may affect cardiac metabolism. The purpose of this study was to determine myocardial substrate preferences during hypothermic machine perfusion and to assess if an anaplerotic substrate was required to maintain the TCA cycle intermediate pool in perfused hearts. METHODS Groups of rat hearts were perfused with carbon-13 (13C)-labeled substrates (acetate, β-hydroxybutyrate, octanoate, with and without propionate) at low and high concentrations. TCA cycle intermediate concentrations, substrate selection, and TCA cycle flux were determined by gas chromatography/mass spectroscopy and 13C magnetic resonance spectroscopy. RESULTS Acetate and octanoate were preferentially oxidized, whereas β-hydroxybutyrate was a minor substrate. TCA cycle intermediate concentrations except fumarate were higher in substrate-containing perfusion groups compared with either the no-substrate perfusion group or the no-ischemia control group. CONCLUSIONS The presence of an exogenous, oxidizable substrate is required to support metabolism in the cold perfused heart. An anaplerotic substrate is not essential to maintain the TCA cycle intermediate pool and support oxidative metabolism under these conditions.
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16
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Wang L, MacGowan GA, Ali S, Dark JH. Ex situ heart perfusion: The past, the present, and the future. J Heart Lung Transplant 2020; 40:69-86. [PMID: 33162304 DOI: 10.1016/j.healun.2020.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 01/06/2023] Open
Abstract
Despite the advancements in medical treatment, mechanical support, and stem cell therapy, heart transplantation remains the most effective treatment for selected patients with advanced heart failure. However, with an increase in heart failure prevalence worldwide, the gap between donor hearts and patients on the transplant waiting list keeps widening. Ex situ machine perfusion has played a key role in augmenting heart transplant activities in recent years by enabling the usage of donation after circulatory death hearts, allowing longer interval between procurement and implantation, and permitting the safe use of some extended-criteria donation after brainstem death hearts. This exciting field is at a hinge point, with 1 commercially available heart perfusion machine, which has been used in hundreds of heart transplantations, and a number of devices being tested in the pre-clinical and Phase 1 clinical trial stage. However, no consensus has been reached over the optimal preservation temperature, perfusate composition, and perfusion parameters. In addition, there is a lack of objective measurement for allograft quality and viability. This review aims to comprehensively summarize the lessons about ex situ heart perfusion as a platform to preserve, assess, and repair donor hearts, which we have learned from the pre-clinical studies and clinical applications, and explore its exciting potential of revolutionizing heart transplantation.
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Affiliation(s)
- Lu Wang
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Guy A MacGowan
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom; Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Simi Ali
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John H Dark
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
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17
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Saemann L, Guo Y, Ding Q, Zhou P, Karck M, Szabó G, Wenzel F. Machine perfusion of circulatory determined death hearts: A scoping review. Transplant Rev (Orlando) 2020; 34:100551. [PMID: 32498975 DOI: 10.1016/j.trre.2020.100551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/25/2020] [Accepted: 04/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ex vivo machine perfusion (EVMP) is reported to can successfully be applied for donor heart preservation. To respond to the organ shortage, some centres also accept hearts from marginal donors such as non-heart beating donors (NHBD) or hearts donated after cardiac death (DCD) for heart transplantation (HTx). Clinical as well as preclinical science on EVMP of DCD hearts seems to be promising but the ideal perfusion practice itself appears unclear. OBJECTIVES In accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA), this systematic review scopes all EVMP techniques for human and animal DCD heart preservation and addresses three specific questions, which refer to (a) the perfusion solutions, (b) the perfusion parameters and respective target values and (c) if possible, a direct comparison between cold static storage (CSS) and EVMP. RESULTS Search results predominantly consisted of animal studies. Either perfusion with a crystalloid or blood-based solution, each with cardioplegic or non-cardioplegic properties was used. Some perfusates were supplemented with specific pharmacological medication to block pathophysiological pathways, which are involved in ischemia/reperfusion injury or edema formation. Besides normothermic EVMP with oxygenated blood, a wide range of temperature was applied in all approaches, with the lowest temperature at 4 °C. Pressure controlled anterograde Langendorff perfusion was applied mostly. If investigated, crystalloid machine perfusion was presented superior to CSS. CONCLUSIONS Only blood based EVMP was introduced into clinical practice. More research, clinical as well as preclinical, is needed to develop the ideal EVMP technique, in terms of blood or crystalloid perfusion.
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Affiliation(s)
- Lars Saemann
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany; Faculty Medical and Life Sciences, Furtwangen University, Jakob-Kienzle-Straße 17, Villingen-Schwenningen 78054, Germany.
| | - Yuxing Guo
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Qingwei Ding
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Pengyu Zhou
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Gábor Szabó
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Folker Wenzel
- Faculty Medical and Life Sciences, Furtwangen University, Jakob-Kienzle-Straße 17, Villingen-Schwenningen 78054, Germany.
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18
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Kvietkauskas M, Leber B, Strupas K, Stiegler P, Schemmer P. Machine Perfusion of Extended Criteria Donor Organs: Immunological Aspects. Front Immunol 2020; 11:192. [PMID: 32180769 PMCID: PMC7057848 DOI: 10.3389/fimmu.2020.00192] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 01/24/2020] [Indexed: 12/20/2022] Open
Abstract
Due to higher vulnerability and immunogenicity of extended criteria donor (ECD) organs used for organ transplantation (Tx), the discovery of new treatment strategies, involving tissue allorecognition pathways, is important. The implementation of machine perfusion (MP) led to improved estimation of the organ quality and introduced the possibility to achieve graft reconditioning prior to Tx. A significant number of experimental and clinical trials demonstrated increasing support for MP as a promising method of ECD organ preservation compared to classical static cold storage. MP reduced ischemia-reperfusion injury resulting in the protection from inadequate activation of innate immunity. However, there are no general agreements on MP protocols, and clinical application is limited. The objective of this comprehensive review is to summarize literature on immunological effects of MP of ECD organs based on experimental studies and clinical trials.
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Affiliation(s)
- Mindaugas Kvietkauskas
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Bettina Leber
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | | | - Philipp Stiegler
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
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19
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Niederberger P, Farine E, Raillard M, Dornbierer M, Freed DH, Large SR, Chew HC, MacDonald PS, Messer SJ, White CW, Carrel TP, Tevaearai Stahel HT, Longnus SL. Heart Transplantation With Donation After Circulatory Death. Circ Heart Fail 2020; 12:e005517. [PMID: 30998395 DOI: 10.1161/circheartfailure.118.005517] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Heart transplantation remains the preferred option for improving quality of life and survival for patients suffering from end-stage heart failure. Unfortunately, insufficient supply of cardiac grafts has become an obstacle. Increasing organ availability with donation after circulatory death (DCD) may be a promising option to overcome the organ shortage. Unlike conventional donation after brain death, DCD organs undergo a period of warm, global ischemia between circulatory arrest and graft procurement, which raises concerns for graft quality. Nonetheless, the potential of DCD heart transplantation is being reconsidered, after reports of more than 70 cases in Australia and the United Kingdom over the past 3 years. Ensuring optimal patient outcomes and generalized adoption of DCD in heart transplantation, however, requires further development of clinical protocols, which in turn require a better understanding of cardiac ischemia-reperfusion injury and the various possibilities to limit its adverse effects. Thus, we aim to provide an overview of the knowledge obtained with preclinical studies in animal models of DCD heart transplantation, to facilitate and promote the most effective and efficient advancement in preclinical research. A literature search of the PubMed database was performed to identify all relevant preclinical studies in DCD heart transplantation. Specific aspects relevant for DCD heart transplantation were analyzed, including animal models, graft procurement and storage conditions, cardioprotective approaches, and graft evaluation strategies. Several potential therapeutic strategies for optimizing graft quality are identified, and recommendations for further preclinical research are provided.
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Affiliation(s)
- Petra Niederberger
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Emilie Farine
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Mathieu Raillard
- Experimental Surgery Unit (ESI), Experimental Surgery Unit, Department for BioMedical Research and Vetsuisse Faculty, Department of Clinical Veterinary Medicine, Institute of Anaesthesiology and Pain Therapy, University of Bern, Switzerland (M.R.)
| | - Monika Dornbierer
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Darren H Freed
- Cardiac Surgery, University of Alberta, Edmonton, Canada (D.H.F., C.W.W.)
| | - Stephen R Large
- Department of Transplantation, Royal Papworth Hospital, Papworth Everard, Cambridge, United Kingdom (S.R.L., S.J.M.)
| | - Hong C Chew
- St Vincent's Hospital, University of New South Wales, Victor Chang Cardiac Research Institute, Sydney, Australia (H.C.C., P.S.M.)
| | - Peter S MacDonald
- St Vincent's Hospital, University of New South Wales, Victor Chang Cardiac Research Institute, Sydney, Australia (H.C.C., P.S.M.)
| | - Simon J Messer
- Department of Transplantation, Royal Papworth Hospital, Papworth Everard, Cambridge, United Kingdom (S.R.L., S.J.M.)
| | | | - Thierry P Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Hendrik T Tevaearai Stahel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Sarah L Longnus
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
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20
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Vela RJ, Jessen ME, Peltz M. Ice, ice, maybe? Is it time to ditch the igloo cooler? Benefits of machine perfusion preservation of donor hearts. Artif Organs 2019; 44:220-227. [DOI: 10.1111/aor.13599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Ryan J. Vela
- Department of Cardiovascular and Thoracic Surgery University of Texas Southwestern Medical Center Dallas Texas
| | - Michael E. Jessen
- Department of Cardiovascular and Thoracic Surgery University of Texas Southwestern Medical Center Dallas Texas
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery University of Texas Southwestern Medical Center Dallas Texas
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21
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Optimizing organs for transplantation; advancements in perfusion and preservation methods. Transplant Rev (Orlando) 2019; 34:100514. [PMID: 31645271 DOI: 10.1016/j.trre.2019.100514] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/20/2019] [Accepted: 10/11/2019] [Indexed: 02/06/2023]
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22
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23
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Impact of Donor Core Body Temperature on Graft Survival After Heart Transplantation. Transplantation 2019; 102:1891-1900. [PMID: 29994980 DOI: 10.1097/tp.0000000000002337] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND A previous donor intervention trial found that induction of mild therapeutic hypothermia in the brain-dead donor reduced the dialysis requirement after kidney transplantation. Consequences on the performance of cardiac allografts after transplantation were not explored to date. METHODS Cohort study investigating 3-year heart allograft survival according to spontaneous core body temperature (CBT) assessed on the day of organ procurement. The study is nested in the database of the randomized trial of donor pretreatment with low-dose dopamine (ClinicalTrials.gov identifier: NCT000115115). RESULTS Ninety-nine heart transplant recipients who had received a cardiac allograft from a multiorgan donor enrolled in the dopamine trial were grouped by tertiles of the donor's CBT assessed by a mere temperature reading 4 to 20 hours before procurement (lowest, 32.0-36.2°C; middle, 36.3-36.8°C; highest, 36.9-38.8°C). Baseline characteristics considering demographics of donors and recipients, concomitant donor treatments, donor hemodynamic, and respiratory parameters as well as underlying cardiac diseases in recipients, pretransplant hemodynamic assessments, including pretransplant inotropic/mechanical support, urgency, and waiting time were similar. A lower CBT was associated with inferior heart allograft survival (hazard ratio, 0.53; 95% confidence interval, 0.31-0.93, per tertile; P = 0.02, and hazard ratio, 0.68; 95% confidence interval, 0.50-0.93°C; P = 0.02) when CBT was included as continuous explanatory variable in the Cox regression analysis. CONCLUSIONS A lower CBT in the brain-dead donor before procurement may associate with an unfavorable clinical course after heart transplantation. More research is required, before therapeutic hypothermia can routinely be used in multiorgan donors when a cardiac transplantation is intended.
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24
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Abstract
This article summarizes recent knowledge and clinical advances in machine perfusion (MP) of thoracic organs. MP of thoracic organs has gained much attention during the last decade. Clinical studies are investigating the role of MP to preserve, resuscitate, and assess heart and lungs prior to transplantation. Currently, MP of the cardiac allograft is essential in all type DCD heart transplantation while MP of the pulmonary allograft is mandatory in uncontrolled DCD lung transplantation. MP of thoracic organs also offers an exciting platform to further investigate downregulation of the innate and adaptive immunity prior to reperfusion of the allograft in recipients. MP provides a promising technology that allows pre-transplant preservation, resuscitation, assessment, repair, and conditioning of cardiac and pulmonary allografts outside the body in a near physiologic state prior to planned transplantation. Results of ongoing clinical trials are awaited to estimate the true clinical value of this new technology in advancing the field of heart and lung transplantation by increasing the total number and the quality of available organs and by further improving recipient early and long-term outcome.
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Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, KU Leuven University, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
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25
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A New Multi-Mode Perfusion System for Ex Vivo Heart Perfusion Study. J Med Syst 2017; 42:25. [PMID: 29273867 DOI: 10.1007/s10916-017-0882-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
Abstract
Ex vivo heart perfusion has been shown to be an effective means of facilitating the resuscitation and assessment of donor hearts for cardiac transplantation. Over the last ten years however, only a few ex vivo perfusion systems have been developed for this application. While results have been promising, a system capable of facilitating multiple perfusion strategies on the same platform has not yet been realized. In this paper, the design, development and testing of a novel and modular ex vivo perfusion system is described. The system is capable of operating in three unique primary modes: the traditional Langendorff Mode, Pump-Supported Working-Mode, and Passive Afterload Working-Mode. In each mode, physiological hemodynamic parameters can be produced by managing perfusion settings. To evaluate heart viability, six experiments were conducted using porcine hearts and measuring several parameters including: pH, aortic pressure, lactate metabolism, coronary vascular resistance (CVR), and myocardial oxygen consumption. Pressure-volume relationship measurements were used to assess left ventricular contractility in each Working Mode. Hemodynamic and metabolic conditions remained stable and consistent across 4 h of ex vivo heart perfusion on the ex vivo perfusion system, validating the system as a viable platform for future development of novel preservation and assessment strategies.
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26
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Abstract
PURPOSE OF REVIEW Despite continued expansion in the use of extended-criteria donor hearts following donation after brain death, there remains an unacceptable discrepancy between the supply of suitable donor hearts and the demand from increasing recipient numbers on transplant wait lists. Until recently, the additional approach of utilizing organs following donation after circulatory death (DCD) had not been possible for clinical heart transplantation in the modern era. This review describes relevant advances in translational research and provides an update on the favourable adoption of this donation pathway for clinical heart transplantation. RECENT FINDINGS The use of an ex-situ transportable cardiac perfusion platform together with modified cardioplegia, supplemented with postconditioning agents, has allowed three centres to report successful transplantation of distantly procured human DCD hearts. This has been achieved by utilizing either a method of direct procurement and ex-situ perfusion on the device or through an initial in-situ reanimation with extracorporeal normothermic regional perfusion prior to ex-situ perfusion. SUMMARY DCD heart transplantation is feasible with excellent early outcomes. In the face of continued and significant donor organ shortage and inevitable wait list attrition, the rejection of suitable DCD hearts, in jurisdictions permitting this donation pathway, is increasingly difficult to justify.
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27
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Thoma A, Farrokhyar F, Waltho D, Braga LH, Sprague S, Goldsmith CH. Users' guide to the surgical literature: how to assess a noninferiority trial. Can J Surg 2017; 60:426-432. [PMID: 29173262 DOI: 10.1503/cjs.000317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
SUMMARY A well-planned randomized controlled trial (RCT) is the most optimal study design to determine if a novel surgical intervention is any different than a prevailing one. Traditionally, when we want to show that a new surgical intervention is superior to a standard one, we analyze data from an RCT to see if the null hypothesis of "no difference" can be rejected (i.e., the 2 surgical interventions have the same effect). A noninferiority RCT design seeks to determine whether a new intervention is not worse than a prevailing (standard) one within an acceptable margin of risk or benefit, referred to as the "noninferiority margin." In the last decade, we have observed an increase in the publication of noninferiority RCTs. This article explores this type of study design and discusses the tools that can be used to appraise such a study.
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Affiliation(s)
- Achilleas Thoma
- Hamilton, Ont. (Thoma); the Surgical Outcomes Research Center, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Thoma, Farrokhyar, Braga, Goldsmith); the Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Thoma, Farrokhyar, Sprague, Goldsmith); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (Waltho); the Division of Urology, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Braga); the Faculty of Health Sciences, Simon Fraser University, Burnaby, BC (Goldsmith); and the Division of Orthopedic Surgery, Department of Surgery, Faculty of Health ciences, McMaster University, Hamilton, Ont. (Sprague)
| | - Forough Farrokhyar
- Hamilton, Ont. (Thoma); the Surgical Outcomes Research Center, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Thoma, Farrokhyar, Braga, Goldsmith); the Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Thoma, Farrokhyar, Sprague, Goldsmith); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (Waltho); the Division of Urology, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Braga); the Faculty of Health Sciences, Simon Fraser University, Burnaby, BC (Goldsmith); and the Division of Orthopedic Surgery, Department of Surgery, Faculty of Health ciences, McMaster University, Hamilton, Ont. (Sprague)
| | - Daniel Waltho
- Hamilton, Ont. (Thoma); the Surgical Outcomes Research Center, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Thoma, Farrokhyar, Braga, Goldsmith); the Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Thoma, Farrokhyar, Sprague, Goldsmith); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (Waltho); the Division of Urology, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Braga); the Faculty of Health Sciences, Simon Fraser University, Burnaby, BC (Goldsmith); and the Division of Orthopedic Surgery, Department of Surgery, Faculty of Health ciences, McMaster University, Hamilton, Ont. (Sprague)
| | | | - Sheila Sprague
- Hamilton, Ont. (Thoma); the Surgical Outcomes Research Center, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Thoma, Farrokhyar, Braga, Goldsmith); the Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Thoma, Farrokhyar, Sprague, Goldsmith); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (Waltho); the Division of Urology, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Braga); the Faculty of Health Sciences, Simon Fraser University, Burnaby, BC (Goldsmith); and the Division of Orthopedic Surgery, Department of Surgery, Faculty of Health ciences, McMaster University, Hamilton, Ont. (Sprague)
| | - Charlie H Goldsmith
- Hamilton, Ont. (Thoma); the Surgical Outcomes Research Center, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Thoma, Farrokhyar, Braga, Goldsmith); the Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Thoma, Farrokhyar, Sprague, Goldsmith); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (Waltho); the Division of Urology, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Braga); the Faculty of Health Sciences, Simon Fraser University, Burnaby, BC (Goldsmith); and the Division of Orthopedic Surgery, Department of Surgery, Faculty of Health ciences, McMaster University, Hamilton, Ont. (Sprague)
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28
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Abstract
Although total body perfusion with extracorporeal life support (ECLS) can be maintained for weeks, individual organ perfusion beyond 12 hours has yet to be achieved clinically. Normothermic ex situ heart perfusion (ESHP) offers the potential for prolonged cardiac preservation. We developed an ESHP system to study the effect of perfusate variables on organ preservation, with the ultimate goal of extending organ perfusion for ≥24 hours. Forty porcine hearts were perfused for a target of 12 hours. Hearts that maintained electromechanical activity and had a <3× increase in vascular resistance were considered successful preservations. Perfusion variables, metabolic byproducts, and histopathology were monitored and sampled to identify factors associated with preservation failure. Twenty-two of 40 hearts were successfully preserved at 12 hours. Successful 12 hour experiments demonstrated lower potassium (4.3 ± 0.8 vs. 5.0 ± 1.2 mmol/L; p = 0.018) and lactate (3.5 ± 2.8 vs. 4.5 ± 2.9 mmol/L; p = 0.139) levels, and histopathology revealed less tissue damage (p = 0.003) and less weight gain (p = 0.072). Results of these early experiments suggest prolonged ESHP is feasible, and that elevated lactate and potassium levels are associated with organ failure. Further studies are necessary to identify the ideal perfusate for normothermic ESHP.
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Targeting the Innate Immune Response to Improve Cardiac Graft Recovery after Heart Transplantation: Implications for the Donation after Cardiac Death. Int J Mol Sci 2016; 17:ijms17060958. [PMID: 27322252 PMCID: PMC4926491 DOI: 10.3390/ijms17060958] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 05/30/2016] [Accepted: 06/01/2016] [Indexed: 12/26/2022] Open
Abstract
Heart transplantation (HTx) is the ultimate treatment for end-stage heart failure. The number of patients on waiting lists for heart transplants, however, is much higher than the number of available organs. The shortage of donor hearts is a serious concern since the population affected by heart failure is constantly increasing. Furthermore, the long-term success of HTx poses some challenges despite the improvement in the management of the short-term complications and in the methods to limit graft rejection. Myocardial injury occurs during transplantation. Injury initiated in the donor as result of brain or cardiac death is exacerbated by organ procurement and storage, and is ultimately amplified by reperfusion injury at the time of transplantation. The innate immune system is a mechanism of first-line defense against pathogens and cell injury. Innate immunity is activated during myocardial injury and produces deleterious effects on the heart structure and function. Here, we briefly discuss the role of the innate immunity in the initiation of myocardial injury, with particular focus on the Toll-like receptors and inflammasome, and how to potentially expand the donor population by targeting the innate immune response.
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Leprince P, Popov AF, Simon AR, Benk C, Siepe M. Ex vivoperfusion of the heart with the use of the Organ Care System. Eur J Cardiothorac Surg 2016; 49:1318-20. [DOI: 10.1093/ejcts/ezw075] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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