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Chaban R, Ileka I, McGrath G, Kinoshita K, Habibabady Z, Ma M, Diaz V, Maenaka A, Calhoun A, Dufault M, Rosales I, Laguerre CM, Sanatkar SA, Burdorf L, Ayares DL, Eyestone W, Sardana P, Kuravi K, Sorrells L, Lederman S, Lucas CG, Prather RS, Wells KD, Whitworth KM, Cooper DKC, Pierson RN. Extended survival of 9- and 10-gene-edited pig heart xenografts with ischemia minimization and CD154 costimulation blockade-based immunosuppression. J Heart Lung Transplant 2024:S1053-2498(24)01777-7. [PMID: 39097214 DOI: 10.1016/j.healun.2024.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/18/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024] Open
Abstract
BACKGROUND Xenotransplantation has made significant advances recently using pigs genetically engineered to remove carbohydrate antigens, either alone or with addition of various human complement, coagulation, and anti-inflammatory ''transgenes''. Here we evaluated results associated with gene-edited (GE) pig hearts transplanted in baboons using an established costimulation-based immunosuppressive regimen and a cold-perfused graft preservation technique. METHODS Eight baboons received heterotopic abdominal heart transplants from 3-GE (GalKO.β4GalNT2KO.hCD55, n = 3), 9-GE (GalKO.β4GalNT2KO.GHRKO.hCD46.hCD55. TBM.EPCR.hCD47. HO-1, n = 3) or 10-G (9-GE+CMAHKO, n = 2) pigs using Steen's cold continuous perfusion for ischemia minimization. Immunosuppression (IS) included induction with anti-thymocyte globulin and αCD20, ongoing αCD154, MMF, and tapered corticosteroid. RESULTS All three 3-GE grafts functioned well initially, but failed within 5 days. One 9-GE graft was lost intraoperatively due to a technical issue and another was lost at POD 13 due to antibody mediated rejection (AMR) in a baboon with a strongly positive pre-operative cross-match. One 10-GE heart failed at POD113 with combined cellular and antibody mediated rejection. One 9-GE and one 10-GE hearts had preserved graft function with normal myocardium on protocol biopsies, but exhibited slowly progressive graft hypertrophy until elective necropsy at POD393 and 243 respectively. Elevated levels of IL-6, MCP-1, C-reactive protein, and human thrombomodulin were variably associated with conditioning, the transplant procedure, and clinically significant postoperative events. CONCLUSION Relative to reference genetics without thrombo-regulatory and anti-inflammatory gene expression, 9- or 10-GE pig hearts exhibit promising performance in the context of a clinically applicable regimen including ischemia minimization and αCD154-based IS, justifying further evaluation in an orthotopic model.
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Affiliation(s)
- Ryan Chaban
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Cardiovascular Surgery, University Hospital of Mainz, Mainz, Germany
| | - Ikechukwu Ileka
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gannon McGrath
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kohei Kinoshita
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Zahra Habibabady
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Madelyn Ma
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Victoria Diaz
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Akihiro Maenaka
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anthony Calhoun
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Megan Dufault
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ivy Rosales
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christiana M Laguerre
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Seyed-Amir Sanatkar
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lars Burdorf
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Revivicor, Inc., Blacksburg, Virginia
| | | | | | | | | | | | | | - Caroline G Lucas
- National Swine Resource and Research Center (NSRRC), Animal Science Research Center, University of Missouri, Columbia, Missouri
| | - Randall S Prather
- National Swine Resource and Research Center (NSRRC), Animal Science Research Center, University of Missouri, Columbia, Missouri
| | - Kevin D Wells
- National Swine Resource and Research Center (NSRRC), Animal Science Research Center, University of Missouri, Columbia, Missouri
| | - Kristin M Whitworth
- National Swine Resource and Research Center (NSRRC), Animal Science Research Center, University of Missouri, Columbia, Missouri
| | - David K C Cooper
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Richard N Pierson
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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2
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Schmoeckel M, Längin M, Reichart B, Abicht JM, Bender M, Michel S, Kamla CE, Denner J, Tönjes RR, Schwinzer R, Marckmann G, Wolf E, Brenner P, Hagl C. Current Status of Cardiac Xenotransplantation: Report of a Workshop of the German Heart Transplant Centers, Martinsried, March 3, 2023. Thorac Cardiovasc Surg 2024; 72:273-284. [PMID: 38154473 PMCID: PMC11147670 DOI: 10.1055/a-2235-8854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/22/2023] [Indexed: 12/30/2023]
Abstract
This report comprises the contents of the presentations and following discussions of a workshop of the German Heart Transplant Centers in Martinsried, Germany on cardiac xenotransplantation. The production and current availability of genetically modified donor pigs, preservation techniques during organ harvesting, and immunosuppressive regimens in the recipient are described. Selection criteria for suitable patients and possible solutions to the problem of overgrowth of the xenotransplant are discussed. Obviously microbiological safety for the recipient and close contacts is essential, and ethical considerations to gain public acceptance for clinical applications are addressed. The first clinical trial will be regulated and supervised by the Paul-Ehrlich-Institute as the National Competent Authority for Germany, and the German Heart Transplant Centers agreed to cooperatively select the first patients for cardiac xenotransplantation.
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Affiliation(s)
- Michael Schmoeckel
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
| | - Matthias Längin
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Bruno Reichart
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Jan-Michael Abicht
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Martin Bender
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Sebastian Michel
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | | | - Joachim Denner
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Institut für Virologie, Fachbereich für Veterinärmedizin, Freie Universität Berlin, Berlin, Germany
| | - Ralf Reinhard Tönjes
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Paul-Ehrlich-Institut, Langen, Germany
| | - Reinhard Schwinzer
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Georg Marckmann
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Institut für Ethik, Geschichte und Theorie der Medizin, LMU München, Germany
| | - Eckhard Wolf
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Lehrstuhl für Molekulare Tierzucht und Biotechnologie, Genzentrum der LMU München, Germany
| | - Paolo Brenner
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
- DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung e.V.), Partner Site Munich, Germany
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3
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Khush KK, Bernat JL, Pierson RN, Silverman HJ, Parent B, Glazier AK, Adams AB, Fishman JA, Gusmano M, Hawthorne WJ, Homan ME, Hurst DJ, Latham S, Park CG, Maschke KJ, Mohiuddin MM, Montgomery RA, Odim J, Pentz RD, Reichart B, Savulescu J, Wolpe PR, Wong RP, Fenton KN. Research opportunities and ethical considerations for heart and lung xenotransplantation research: A report from the National Heart, Lung, and Blood Institute workshop. Am J Transplant 2024; 24:918-927. [PMID: 38514013 PMCID: PMC11144553 DOI: 10.1016/j.ajt.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
Xenotransplantation offers the potential to meet the critical need for heart and lung transplantation presently constrained by the current human donor organ supply. Much was learned over the past decades regarding gene editing to prevent the immune activation and inflammation that cause early organ injury, and strategies for maintenance of immunosuppression to promote longer-term xenograft survival. However, many scientific questions remain regarding further requirements for genetic modification of donor organs, appropriate contexts for xenotransplantation research (including nonhuman primates, recently deceased humans, and living human recipients), and risk of xenozoonotic disease transmission. Related ethical questions include the appropriate selection of clinical trial participants, challenges with obtaining informed consent, animal rights and welfare considerations, and cost. Research involving recently deceased humans has also emerged as a potentially novel way to understand how xeno-organs will impact the human body. Clinical xenotransplantation and research involving decedents also raise ethical questions and will require consensus regarding regulatory oversight and protocol review. These considerations and the related opportunities for xenotransplantation research were discussed in a workshop sponsored by the National Heart, Lung, and Blood Institute, and are summarized in this meeting report.
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Affiliation(s)
- Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Richard N Pierson
- Department of Surgery and Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Henry J Silverman
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brendan Parent
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Alexandra K Glazier
- New England Donor Services, Waltham, Massachusetts, USA; School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Andrew B Adams
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jay A Fishman
- Transplant Infectious Disease and MGH Transplant Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Gusmano
- College of Health, Lehigh University, Bethlehem, Pennsylvania, USA
| | - Wayne J Hawthorne
- Department of Surgery, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia
| | - Mary E Homan
- Department of Theology and Ethics, CommonSpirit Health, Chicago, Illinois, USA
| | - Daniel J Hurst
- Department of Family Medicine, Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Stephen Latham
- Interdisciplinary Center for Bioethics, Yale University, New Haven, Connecticut, USA
| | - Chung-Gyu Park
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Muhammad M Mohiuddin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Robert A Montgomery
- NYU Langone Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Jonah Odim
- Transplantation Branch, Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Rebecca D Pentz
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Bruno Reichart
- Department of Cardiac Surgery, Ludwig-Maximillian University, Munich, Germany
| | - Julian Savulescu
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Paul Root Wolpe
- Center for Ethics and Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Renee P Wong
- Heart Failure and Arrhythmias Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Kathleen N Fenton
- Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, and Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
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4
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Hurst DJ, Padilla L, Merlocco A, Rodger D, Bobier C, Gray WH, Sorabella R, Cooper DKC, Pierson RN. Pediatric Cardiac Xenotransplantation: Recommendations for the Ethical Design of Clinical Trials. Transplantation 2024:00007890-990000000-00678. [PMID: 38419158 DOI: 10.1097/tp.0000000000004968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
For children with complex congenital heart problems, cardiac allotransplantation is sometimes the best therapeutic option. However, availability of hearts for pediatric patients is limited, resulting in a long and growing waitlist, and a high mortality rate while waiting. Cardiac xenotransplantation has been proposed as one therapeutic alternative for neonates and infants, either in lieu of allotransplantation or as a bridge until an allograft becomes available. Scientific and clinical developments in xenotransplantation appear likely to permit cardiac xenotransplantation clinical trials in adults in the coming years. The ethical issues around xenotransplantation of the heart and other organs and tissues have recently been examined, but to date, only limited literature is available on the ethical issues that are attendant with pediatric heart xenotransplantation. Here, we summarize the ethical issues, focusing on (1) whether cardiac xenotransplantation should proceed in adults or children first, (2) pediatric recipient selection for initial xenotransplantation trials, (3) special problems regarding informed consent in this context, and (4) related psychosocial and public perception considerations. We conclude with specific recommendations regarding ethically informed design of pediatric heart xenotransplantation trials.
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Affiliation(s)
- Daniel J Hurst
- Department of Family Medicine, Rowan-Virtua School of Osteopathic Medicine, Stratford, NJ
| | - Luz Padilla
- Department of Surgery, Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Anthony Merlocco
- Department of Cardiology, University of Tennessee Health Science Center, Memphis, TN
| | - Daniel Rodger
- Institute of Health and Social Care, School of Allied and Community Health, London South Bank University, London, United Kingdom
- Department of Psychological Sciences, Birkbeck College, University of London, London, United Kingdom
| | - Christopher Bobier
- Department of Theology and Philosophy, Saint Mary's University of Minnesota, Winona, MN
| | - William H Gray
- Department of Surgery, Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Robert Sorabella
- Department of Surgery, Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MN
| | - Richard N Pierson
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MN
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5
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Jou S, Mendez SR, Feinman J, Mitrani LR, Fuster V, Mangiola M, Moazami N, Gidea C. Heart transplantation: advances in expanding the donor pool and xenotransplantation. Nat Rev Cardiol 2024; 21:25-36. [PMID: 37452122 DOI: 10.1038/s41569-023-00902-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
Approximately 65 million adults globally have heart failure, and the prevalence is expected to increase substantially with ageing populations. Despite advances in pharmacological and device therapy of heart failure, long-term morbidity and mortality remain high. Many patients progress to advanced heart failure and develop persistently severe symptoms. Heart transplantation remains the gold-standard therapy to improve the quality of life, functional status and survival of these patients. However, there is a large imbalance between the supply of organs and the demand for heart transplants. Therefore, expanding the donor pool is essential to reduce mortality while on the waiting list and improve clinical outcomes in this patient population. A shift has occurred to consider the use of organs from donors with hepatitis C virus, HIV or SARS-CoV-2 infection. Other advances in this field have also expanded the donor pool, including opt-out donation policies, organ donation after circulatory death and xenotransplantation. We provide a comprehensive overview of these various novel strategies, provide objective data on their safety and efficacy, and discuss some of the unresolved issues and controversies of each approach.
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Affiliation(s)
- Stephanie Jou
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA.
| | - Sean R Mendez
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Jason Feinman
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Lindsey R Mitrani
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Massimo Mangiola
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - Claudia Gidea
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
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6
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Goerlich CE, Griffith BP, Shah A, Treffalls JA, Zhang T, Lewis B, Tatarov I, Hershfeld A, Sentz F, Braileanu G, Ayares D, Singh AK, Mohiuddin MM. A Standardized Approach to Orthotopic (Life-supporting) Porcine Cardiac Xenotransplantation in a Nonhuman Primate Model. Transplantation 2023; 107:1718-1728. [PMID: 36706064 DOI: 10.1097/tp.0000000000004508] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Cardiac xenotransplantation from swine has been proposed to "bridge the gap" in supply for heart failure patients requiring transplantation. Recent preclinical success using genetically modified pig donors in baboon recipients has demonstrated survival greater than 6 mo, with a modern understanding of xenotransplantation immunobiology and continued experience with large animal models of cardiac xenotransplantation. As a direct result of this expertise, the Food and Drug Administration approved the first in-human transplantation of a genetically engineered cardiac xenograft through an expanded access application for a single patient. This clinical case demonstrated the feasibility of xenotransplantation. Although this human study demonstrated proof-of-principle application of cardiac xenotransplantation, further regulatory oversight by the Food and Drug Administration may be required with preclinical trials in large animal models of xenotransplantation with long-term survival before approval of a more formalized clinical trial. Here we detail our surgical approach to pig-to-primate large animal models of orthotopic cardiac xenotransplantation, and the postoperative care of the primate recipient, both in the immediate postoperative period and in the months thereafter. We also detail xenograft surveillance methods and common issues that arise in the postoperative period specific to this model and ways to overcome them. These studies require multidisciplinary teams and expertise in orthotopic transplantation (cardiac surgery, anesthesia, and cardiopulmonary bypass), immunology, genetic engineering, and experience in handling large animal donors and recipients, which are described here. This article serves to reduce the barriers to entry into a field with ever-growing enthusiasm, but demands expertise knowledge and experience to be successful.
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Affiliation(s)
- Corbin E Goerlich
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Aakash Shah
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - John A Treffalls
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Tianshu Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Billeta Lewis
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ivan Tatarov
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Alena Hershfeld
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Faith Sentz
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Gheorghe Braileanu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - Avneesh K Singh
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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7
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Moazami N, Stern JM, Khalil K, Kim JI, Narula N, Mangiola M, Weldon EP, Kagermazova L, James L, Lawson N, Piper GL, Sommer PM, Reyentovich A, Bamira D, Saraon T, Kadosh BS, DiVita M, Goldberg RI, Hussain ST, Chan J, Ngai J, Jan T, Ali NM, Tatapudi VS, Segev DL, Bisen S, Jaffe IS, Piegari B, Kowalski H, Kokkinaki M, Monahan J, Sorrells L, Burdorf L, Boeke JD, Pass H, Goparaju C, Keating B, Ayares D, Lorber M, Griesemer A, Mehta SA, Smith DE, Montgomery RA. Pig-to-human heart xenotransplantation in two recently deceased human recipients. Nat Med 2023; 29:1989-1997. [PMID: 37488288 DOI: 10.1038/s41591-023-02471-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/26/2023] [Indexed: 07/26/2023]
Abstract
Genetically modified xenografts are one of the most promising solutions to the discrepancy between the numbers of available human organs for transplantation and potential recipients. To date, a porcine heart has been implanted into only one human recipient. Here, using 10-gene-edited pigs, we transplanted porcine hearts into two brain-dead human recipients and monitored xenograft function, hemodynamics and systemic responses over the course of 66 hours. Although both xenografts demonstrated excellent cardiac function immediately after transplantation and continued to function for the duration of the study, cardiac function declined postoperatively in one case, attributed to a size mismatch between the donor pig and the recipient. For both hearts, we confirmed transgene expression and found no evidence of cellular or antibody-mediated rejection, as assessed using histology, flow cytometry and a cytotoxic crossmatch assay. Moreover, we found no evidence of zoonotic transmission from the donor pigs to the human recipients. While substantial additional work will be needed to advance this technology to human trials, these results indicate that pig-to-human heart xenotransplantation can be performed successfully without hyperacute rejection or zoonosis.
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Affiliation(s)
- Nader Moazami
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA.
| | - Jeffrey M Stern
- New York University Langone Transplant Institute, New York, NY, USA
| | - Karen Khalil
- New York University Langone Transplant Institute, New York, NY, USA
| | - Jacqueline I Kim
- New York University Langone Transplant Institute, New York, NY, USA
| | - Navneet Narula
- Department of Pathology, New York University Langone Health, New York, NY, USA
| | - Massimo Mangiola
- New York University Langone Transplant Institute, New York, NY, USA
| | - Elaina P Weldon
- New York University Langone Transplant Institute, New York, NY, USA
| | - Larisa Kagermazova
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, NY, USA
| | - Les James
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - Nikki Lawson
- New York University Langone Transplant Institute, New York, NY, USA
| | - Greta L Piper
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Philip M Sommer
- Department of Anesthesiology, New York University Langone Health, New York, NY, USA
| | - Alex Reyentovich
- Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Daniel Bamira
- Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Tajinderpal Saraon
- Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Bernard S Kadosh
- Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Michael DiVita
- Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Randal I Goldberg
- Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Syed T Hussain
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - Justin Chan
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - Jennie Ngai
- Department of Anesthesiology, New York University Langone Health, New York, NY, USA
| | - Thomas Jan
- Department of Anesthesiology, New York University Langone Health, New York, NY, USA
| | - Nicole M Ali
- New York University Langone Transplant Institute, New York, NY, USA
| | | | - Dorry L Segev
- Department of Surgery, New York University Langone Health, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Shivani Bisen
- New York University Grossman School of Medicine, New York University, New York, NY, USA
| | - Ian S Jaffe
- New York University Grossman School of Medicine, New York University, New York, NY, USA
| | - Benjamin Piegari
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Haley Kowalski
- New York University Grossman School of Medicine, New York University, New York, NY, USA
| | | | | | | | | | - Jef D Boeke
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, NY, USA
- Institute for Systems Genetics, New York University Grossman School of Medicine, New York, NY, USA
| | - Harvey Pass
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - Chandra Goparaju
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - Brendan Keating
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Marc Lorber
- United Therapeutics Corporation, Silver Spring, MD, USA
| | - Adam Griesemer
- New York University Langone Transplant Institute, New York, NY, USA
| | - Sapna A Mehta
- New York University Langone Transplant Institute, New York, NY, USA
| | - Deane E Smith
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
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8
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Benson JM, Wang G, Hutt JA, Wu G, Kaminsky SM, Cram S, Barur R, Donahue JK. Preclinical safety and biodistribution assessment of Ad-KCNH2-G628S administered via atrial painting in New Zealand white rabbits. Basic Clin Pharmacol Toxicol 2023; 133:179-193. [PMID: 37177881 PMCID: PMC10935599 DOI: 10.1111/bcpt.13885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
Post-operative atrial fibrillation (POAF) is the most common complication after cardiac surgery. Despite implementation of several pharmacological strategies, incidence of POAF remains at approximately 30%. An adenovirus vector encoding KCNH2-G628S has proven efficacious in a porcine model of AF. In this preclinical study, 1.5 × 1010 or 1.5 × 1012 Ad-KCNH2-G628S vector particles (vp) were applied to the atrial epicardium or 1.5 × 1012 vp were applied to the whole epicardial surface of New Zealand White rabbits. Saline and vector vehicle served as procedure controls. Animals were followed for up to 42 days. Vector genomes persisted in the atria up to 42 days, with no distribution to extra-thoracic organs. There were no adverse effects attributable to test article on standard toxicological endpoints or on blood pressure, left atrial or ventricular ejection fractions, electrocardiographic parameters, or serum IL-6 or troponin concentrations. Mononuclear infiltration of the myocardium of the atrial free walls of low-dose, but not high-dose animals was observed at 7 and 21 days, but these changes did not persist or affect cardiac function. After scaling for heart size, results indicate the test article is safe at doses up to 25 times the maximum proposed for the human clinical trial.
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Affiliation(s)
- Janet M. Benson
- Applied Toxicology Program, Lovelace Biomedical Research Institute, Albuquerque, NM 87108, USA
| | - Gensheng Wang
- Applied Toxicology Program, Lovelace Biomedical Research Institute, Albuquerque, NM 87108, USA
- Baxter International, Inc. Deerfield, IL 60015, USA
| | - Julie A. Hutt
- Greenfield Pathology Services, Inc., Greenfield, IN 46140, USA
| | - Guodong Wu
- Applied Toxicology Program, Lovelace Biomedical Research Institute, Albuquerque, NM 87108, USA
| | - Stephen M. Kaminsky
- Weill Cornell Medicine, Belfer Gene Therapy Core Facility, New York, NY 10021, USA
| | - Sara Cram
- Weill Cornell Medicine, Belfer Gene Therapy Core Facility, New York, NY 10021, USA
| | - Rajeshkumar Barur
- Cardiovascular Medicine, University of Massachusetts Chan Medical School, Worcester, MA 01605, USA
| | - J. Kevin Donahue
- Cardiovascular Medicine, University of Massachusetts Chan Medical School, Worcester, MA 01605, USA
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9
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Chaban R, McGrath G, Habibabady Z, Rosales I, Burdorf L, Ayares DL, Rybak E, Zhang T, Harris DG, Dahi S, Ali F, Parsell DM, Braileanu G, Cheng X, Sievert E, Phelps C, Azimzadeh AM, Pierson RN. Increased human complement pathway regulatory protein gene dose is associated with increased endothelial expression and prolonged survival during ex-vivo perfusion of GTKO pig lungs with human blood. Xenotransplantation 2023; 30:e12812. [PMID: 37504492 DOI: 10.1111/xen.12812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/29/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Expression of human complement pathway regulatory proteins (hCPRP's) such as CD46 or CD55 has been associated with improved survival of pig organ xenografts in multiple different models. Here we evaluate the hypothesis that an increased human CD46 gene dose, through homozygosity or additional expression of a second hCPRP, is associated with increased protein expression and with improved protection from injury when GTKO lung xenografts are perfused with human blood. METHODS Twenty three GTKO lungs heterozygous for human CD46 (GTKO.heteroCD46), 10 lungs homozygous for hCD46 (GTKO.homoCD46), and six GTKO.homoCD46 lungs also heterozygous for hCD55 (GTKO.homoCD46.hCD55) were perfused with human blood for up to 4 h in an ex vivo circuit. RESULTS Relative to GTKO.heteroCD46 (152 min, range 5-240; 6/23 surviving at 4 h), survival was significantly improved for GTKO.homoCD46 (>240 min, range 45-240, p = .034; 7/10 surviving at 4 h) or GTKO.homoCD46.hCD55 lungs (>240 min, p = .001; 6/6 surviving at 4 h). Homozygosity was associated with increased capillary expression of hCD46 (p < .0001). Increased hCD46 expression was associated with significantly prolonged lung survival (p = .048),) but surprisingly not with reduction in measured complement factor C3a. Hematocrit, monocyte count, and pulmonary vascular resistance were not significantly altered in association with increased hCD46 gene dose or protein expression. CONCLUSION Genetic engineering approaches designed to augment hCPRP activity - increasing the expression of hCD46 through homozygosity or co-expressing hCD55 with hCD46 - were associated with prolonged GTKO lung xenograft survival. Increased expression of hCD46 was associated with reduced coagulation cascade activation, but did not further reduce complement activation relative to lungs with relatively low CD46 expression. We conclude that coagulation pathway dysregulation contributes to injury in GTKO pig lung xenografts perfused with human blood, and that the survival advantage for lungs with increased hCPRP expression is likely attributable to improved endothelial thromboregulation.
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Affiliation(s)
- Ryan Chaban
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
- Department of Cardiac and Vascular Surgery, University Hospital of Johannes Gutenberg University Mainz, Mainz, Germany
| | - Gannon McGrath
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
| | - Zahra Habibabady
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ivy Rosales
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
| | - Lars Burdorf
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Revivicor, Inc., Blacksburg, Virginia, USA
| | | | - Elana Rybak
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Tianshu Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Donald G Harris
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Siamak Dahi
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Franchesca Ali
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Dawn M Parsell
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gheorghe Braileanu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Xiangfei Cheng
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Evelyn Sievert
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Agnes M Azimzadeh
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Richard N Pierson
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard School of Medicine, Boston, Massachusetts, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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10
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Li S, Anwar IJ, Canning AJ, Vo-Dinh T, Kirk AD, Xu H. Xenorecognition and costimulation of porcine endothelium-derived extracellular vesicles in initiating human porcine-specific T cell immune responses. Am J Transplant 2023; 23:904-919. [PMID: 37054891 PMCID: PMC10330644 DOI: 10.1016/j.ajt.2023.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 04/02/2023] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
Porcine vascular endothelial cells (PECs) form a mechanistic centerpiece of xenograft rejection. Here, we determined that resting PECs release swine leukocyte antigen class I (SLA-I) but not swine leukocyte antigen class-II DR (SLA-DR) expressing extracellular vesicles (EVs) and investigated whether these EVs proficiently initiate xenoreactive T cell responses via direct xenorecognition and costimulation. Human T cells acquired SLA-I+ EVs with or without direct contact to PECs, and these EVs colocalized with T cell receptors. Although interferon gamma-activated PECs released SLA-DR+ EVs, the binding of SLA-DR+ EVs to T cells was sparse. Human T cells demonstrated low levels of proliferation without direct contact to PECs, but marked T cell proliferation was induced following exposure to EVs. EV-induced proliferation proceeded independent of monocytes/macrophages, suggesting that EVs delivered both a T cell receptor signal and costimulation. Costimulation blockade targeting B7, CD40L, or CD11a significantly reduced T cell proliferation to PEC-derived EVs. These findings indicate that endothelial-derived EVs can directly initiate T cell-mediated immune responses, and suggest that inhibiting the release of SLA-I EVs from organ xenografts has the potential to modify the xenograft rejection. We propose a secondary-direct pathway for T cell activation via xenoantigen recognition/costimulation by endothelial-derived EVs.
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Affiliation(s)
- Shu Li
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Imran J Anwar
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Aidan J Canning
- Department of Biomedical Engineering, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tuan Vo-Dinh
- Department of Biomedical Engineering, Duke University School of Medicine, Durham, North Carolina, USA
| | - Allan D Kirk
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA; Department of Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - He Xu
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
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11
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Koh J, Chee HK, Kim KH, Jeong IS, Kim JS, Lee CH, Seo JW. Historical Review and Future of Cardiac Xenotransplantation. Korean Circ J 2023; 53:351-366. [PMID: 37271743 DOI: 10.4070/kcj.2022.0351] [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: 12/09/2022] [Revised: 03/14/2023] [Accepted: 04/05/2023] [Indexed: 06/06/2023] Open
Abstract
Along with the development of immunosuppressive drugs, major advances on xenotransplantation were achieved by understanding the immunobiology of xenograft rejection. Most importantly, three predominant carbohydrate antigens on porcine endothelial cells were key elements provoking hyperacute rejection: α1,3-galactose, SDa blood group antigen, and N-glycolylneuraminic acid. Preformed antibodies binding to the porcine major xenoantigen causes complement activation and endothelial cell activation, leading to xenograft injury and intravascular thrombosis. Recent advances in genetic engineering enabled knock-outs of these major xenoantigens, thus producing xenografts with less hyperacute rejection rates. Another milestone in the history of xenotransplantation was the development of co-stimulation blockaded strategy. Unlike allotransplantation, xenotransplantation requires blockade of CD40-CD40L pathway to prevent T-cell dependent B-cell activation and antibody production. In 2010s, advanced genetic engineering of xenograft by inducing the expression of multiple human transgenes became available. So-called 'multi-gene' xenografts expressing human transgenes such as thrombomodulin and endothelial protein C receptor were introduced, which resulted in the reduction of thrombotic events and improvement of xenograft survival. Still, there are many limitations to clinical translation of cardiac xenotransplantation. Along with technical challenges, zoonotic infection and physiological discordances are major obstacles. Social barriers including healthcare costs also need to be addressed. Although there are several remaining obstacles to overcome, xenotransplantation would surely become the novel option for millions of patients with end-stage heart failure who have limited options to traditional therapeutics.
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Affiliation(s)
- Jiwon Koh
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Keun Chee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Kyung-Hee Kim
- Division of Cardiology, Incheon Sejong Hospital, Incheon, Korea
| | - In-Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Jung-Sun Kim
- Department of Pathology and Translational Genomics, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Bucheon Sejong Hospital, Bucheon, Korea
| | - Jeong-Wook Seo
- Department of Pathology, Incheon Sejong Hospital, Incheon, Korea.
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12
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Schizas N, Nazou G, Angouras DC, Iliopoulos DC, Dedeilias P, Argiriou M. Heart Xenotransplantation: Current Issues and Perspectives. J Tehran Heart Cent 2023; 18:79-81. [PMID: 37637284 PMCID: PMC10459343 DOI: 10.18502/jthc.v18i2.13315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/16/2023] [Indexed: 08/29/2023] Open
Abstract
The Article Abstract is not available.
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13
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Li Q, Lan P. Activation of immune signals during organ transplantation. Signal Transduct Target Ther 2023; 8:110. [PMID: 36906586 PMCID: PMC10008588 DOI: 10.1038/s41392-023-01377-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 03/13/2023] Open
Abstract
The activation of host's innate and adaptive immune systems can lead to acute and chronic graft rejection, which seriously impacts graft survival. Thus, it is particularly significant to clarify the immune signals, which are critical to the initiation and maintenance of rejection generated after transplantation. The initiation of response to graft is dependent on sensing of danger and stranger molecules. The ischemia and reperfusion of grafts lead to cell stress or death, followed by releasing a variety of damage-associated molecular patterns (DAMPs), which are recognized by pattern recognition receptors (PRRs) of host immune cells to activate intracellular immune signals and induce sterile inflammation. In addition to DAMPs, the graft exposed to 'non-self' antigens (stranger molecules) are recognized by the host immune system, stimulating a more intense immune response and further aggravating the graft damage. The polymorphism of MHC genes between different individuals is the key for host or donor immune cells to identify heterologous 'non-self' components in allogeneic and xenogeneic organ transplantation. The recognition of 'non-self' antigen by immune cells mediates the activation of immune signals between donor and host, resulting in adaptive memory immunity and innate trained immunity to the graft, which poses a challenge to the long-term survival of the graft. This review focuses on innate and adaptive immune cells receptor recognition of damage-associated molecular patterns, alloantigens and xenoantigens, which is described as danger model and stranger model. In this review, we also discuss the innate trained immunity in organ transplantation.
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Affiliation(s)
- Qingwen Li
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Peixiang Lan
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China. .,Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China.
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14
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Mehta SA, Saharia KK, Nellore A, Blumberg EA, Fishman JA. Infection and clinical xenotransplantation: Guidance from the Infectious Disease Community of Practice of the American Society of Transplantation. Am J Transplant 2023; 23:309-315. [PMID: 36695690 DOI: 10.1016/j.ajt.2022.12.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/20/2022] [Accepted: 12/10/2022] [Indexed: 01/04/2023]
Abstract
This guidance was developed to summarize current approaches to the potential transmission of swine-derived organisms to xenograft recipients, health care providers, or the public in clinical xenotransplantation. Limited specific data are available on the zoonotic potential of pig pathogens. It is anticipated that the risk of zoonotic infection in xenograft recipients will be determined by organisms present in source animals and relate to the nature and intensity of the immunosuppression used to maintain xenograft function. Based on experience in allotransplantation and with preclinical models, viral infections are of greatest concern, including porcine cytomegalovirus, porcine lymphotropic herpesvirus, and porcine endogenous retroviruses. Sensitive and specific microbiological assays are required for routine microbiological surveillance of source animals and xenograft recipients. Archiving of blood samples from recipients, contacts, and hospital staff may provide a basis for microbiological investigations if infectious syndromes develop. Carefully implemented infection control practices are required to prevent zoonotic pathogen exposures by clinical care providers. Informed consent practices for recipients and their close contacts must convey the lack of specific data for infectious risk assessment. Available data suggest that infectious risks of xenotransplantation are manageable and that clinical trials can advance with carefully developed protocols for pretransplant assessment, syndrome evaluation, and microbiological monitoring.
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Affiliation(s)
- Sapna A Mehta
- Transplant Infectious Diseases, NYU Langone Transplant Institute and NYU Grossman School of Medicine, New York, New York, USA
| | - Kapil K Saharia
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anoma Nellore
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emily A Blumberg
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jay A Fishman
- Transplant and Compromised Host Infectious Disease Program and MGH Transplant Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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15
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Chan JCY, Chaban R, Chang SH, Angel LF, Montgomery RA, Pierson RN. Future of Lung Transplantation: Xenotransplantation and Bioengineering Lungs. Clin Chest Med 2023; 44:201-214. [PMID: 36774165 PMCID: PMC11078107 DOI: 10.1016/j.ccm.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Xenotransplantation promises to alleviate the issue of donor organ shortages and to decrease waiting times for transplantation. Recent advances in genetic engineering have allowed for the creation of pigs with up to 16 genetic modifications. Several combinations of genetic modifications have been associated with extended graft survival and life-supporting function in experimental heart and kidney xenotransplants. Lung xenotransplantation carries specific challenges related to the large surface area of the lung vascular bed, its innate immune system's intrinsic hyperreactivity to perceived 'danger', and its anatomic vulnerability to airway flooding after even localized loss of alveolocapillary barrier function. This article discusses the current status of lung xenotransplantation, and challenges related to immunology, physiology, anatomy, and infection. Tissue engineering as a feasible alternative to develop a viable lung replacement solution is discussed.
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Affiliation(s)
- Justin C Y Chan
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA.
| | - Ryan Chaban
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Cardiovascular Surgery, University Hospital of Johannes Gutenberg University, Langenbeckstr. 1, Bau 505, 5. OG55131 Mainz, Germany
| | - Stephanie H Chang
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA
| | - Luis F Angel
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA
| | - Robert A Montgomery
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA
| | - Richard N Pierson
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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16
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Reichart B, Cooper DKC, Längin M, Tönjes RR, Pierson RN, Wolf E. Cardiac xenotransplantation: from concept to clinic. Cardiovasc Res 2023; 118:3499-3516. [PMID: 36461918 PMCID: PMC9897693 DOI: 10.1093/cvr/cvac180] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 12/05/2022] Open
Abstract
For many patients with terminal/advanced cardiac failure, heart transplantation is the most effective, durable treatment option, and offers the best prospects for a high quality of life. The number of potentially life-saving donated human organs is far fewer than the population who could benefit from a new heart, resulting in increasing numbers of patients awaiting replacement of their failing heart, high waitlist mortality, and frequent reliance on interim mechanical support for many of those deemed among the best candidates but who are deteriorating as they wait. Currently, mechanical assist devices supporting left ventricular or biventricular heart function are the only alternative to heart transplant that is in clinical use. Unfortunately, the complication rate with mechanical assistance remains high despite advances in device design and patient selection and management, and the quality of life of the patients even with good outcomes is only moderately improved. Cardiac xenotransplantation from genetically multi-modified (GM) organ-source pigs is an emerging new option as demonstrated by the consistent long-term success of heterotopic (non-life-supporting) abdominal and life-supporting orthotopic porcine heart transplantation in baboons, and by a recent 'compassionate use' transplant of the heart from a GM pig with 10 modifications into a terminally ill patient who survived for 2 months. In this review, we discuss pig heart xenotransplantation as a concept, including pathobiological aspects related to immune rejection, coagulation dysregulation, and detrimental overgrowth of the heart, as well as GM strategies in pigs to prevent or minimize these problems. Additional topics discussed include relevant results of heterotopic and orthotopic heart transplantation experiments in the pig-to-baboon model, microbiological and virologic safety concepts, and efficacy requirements for initiating formal clinical trials. An adequate regulatory and ethical framework as well as stringent criteria for the selection of patients will be critical for the safe clinical development of cardiac xenotransplantation, which we expect will be clinically tested during the next few years.
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Affiliation(s)
- Bruno Reichart
- Walter Brendel Centre for Experimental Medicine, Ludwig-Maximilians-Universität München, Munich 81377, Germany
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02129, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Matthias Längin
- Department of Anaesthesiology, University Hospital, Ludwig-Maximilians-Universität München, Munich 81377, Germany
| | - Ralf R Tönjes
- Division of Medical Biotechnology, Paul-Ehrlich-Institute, Langen 63225, Germany
| | - Richard N Pierson
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02129, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Eckhard Wolf
- Gene Centre and Centre for Innovative Medical Models (CiMM), Ludwig-Maximilians-Universität München, Munich 81377, Germany
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17
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Goerlich CE, Griffith B, Hanna P, Hong SN, Ayares D, Singh AK, Mohiuddin MM. The growth of xenotransplanted hearts can be reduced with growth hormone receptor knockout pig donors. J Thorac Cardiovasc Surg 2023; 165:e69-e81. [PMID: 34579956 PMCID: PMC8894505 DOI: 10.1016/j.jtcvs.2021.07.051] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/05/2021] [Accepted: 07/13/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Genetically engineered pigs are thought to be an alternative organ source for patients in end-stage heart failure unable to receive a timely allograft. However, cardiac xenografts exhibit growth and diastolic heart failure within 1 month after transplantation. Grafts function for up to 6 months, but only after administration of temsirolimus and afterload-reducing agents to reduce this growth. In this study we investigated the growth and hemodynamics of growth hormone receptor (GHR) knockout xenografts, without the use of adjuncts to prevent intrinsic graft growth after transplantation. METHODS Genetically engineered pig hearts were transplanted orthotopically into weight-matched baboons between 15 and 30 kg, using continuous perfusion preservation before implantation (n = 5). Xenografts included knockout of carbohydrate antigens and knockin of human transgenes for thromboregulation, complement regulation, and inflammation reduction (grafts with intact growth hormone, n = 2). Three grafts contained the additional knockout of GHR (GHR knockout grafts; n = 3). Transthoracic echocardiograms were obtained twice monthly and comprehensively analyzed by a blinded cardiologist. Hemodynamics were measured longitudinally after transplantation. RESULTS All xenografts demonstrated life-supporting function after transplantation. There was no difference in intrinsic growth, measured using septal and posterior wall thickness and left ventricular mass, on transthoracic echocardiogram out to 1 month in either GHR knockout or GHR intact grafts. However, hypertrophy of the septal and posterior wall was markedly elevated by 2 months post transplantation. There was minimal hypertrophy out to 6 months in GHR knockout grafts. Physiologic mismatch was present in all grafts after transplantation, which is largely independent of growth. CONCLUSIONS Xenografts with GHR knockout show reduced post-transplantation xenograft growth using echocardiography >6 months after transplantation, without the need for other adjuncts.
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Affiliation(s)
- Corbin E Goerlich
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Md; Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, Md
| | - Bartley Griffith
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Md
| | - Peter Hanna
- Department of Cardiology, The University of Maryland School of Medicine, Baltimore, Md
| | - Susie N Hong
- Department of Cardiology, The University of Maryland School of Medicine, Baltimore, Md
| | | | - Avneesh K Singh
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Md
| | - Muhammad M Mohiuddin
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Md.
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18
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Accommodation in allogeneic and xenogeneic organ transplantation: Prevalence, impact, and implications for monitoring and for therapeutics. Hum Immunol 2023; 84:5-17. [PMID: 36244871 DOI: 10.1016/j.humimm.2022.08.001] [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: 06/22/2022] [Accepted: 08/01/2022] [Indexed: 11/04/2022]
Abstract
Accommodation refers to acquired resistance of organs or tissues to immune or inflammatory reactions that might otherwise cause severe injury or rejection. As first observed in ABO-incompatible kidney transplants and heterotopic cardiac xenografts, accommodation was identified when organ transplants continued to function despite the presence of anti-graft antibodies and/or other reactants in the blood of recipients. Recent evidence suggests many and perhaps most organ transplants have accommodation, as most recipients mount B cell responses specific for the graft. Wide interest in the impact of graft-specific antibodies on the outcomes of transplants prompts questions about which mechanisms confer protection against such antibodies, how accommodation might be detected and whether and how rejection could be superimposed on accommodation. Xenotransplantation offers a unique opportunity to address these questions because immune responses to xenografts are easily detected and the pathogenic impact of immune responses is so severe. Xenotransplantation also provides a compelling need to apply these and other insights to decrease the intensity and toxicity of immunosuppression that otherwise could limit clinical application.
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19
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Cascalho M, Platt JL. TNFRSF13B in B cell responses to organ transplantation. Hum Immunol 2023; 84:27-33. [PMID: 36333165 PMCID: PMC10429825 DOI: 10.1016/j.humimm.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/14/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022]
Abstract
Antibodies directed against organ transplants are thought to pose the most vexing hurdle to enduring function and survival of the transplants, particularly organ xenotransplants, and accordingly basic and clinical investigation has focused on elucidating the specificity and pathogenicity of graft-specific antibodies. While much has been learned about these matters, far less is known about the B cells producing graft-specific antibodies and why these antibodies appear to injure some grafts but not others. With the goal of addressing those questions, we have investigated the properties of tumor necrosis factor receptor super family-13B (TNFRSF13B), which regulates various aspects of B cell responses. A full understanding of the functions of TNFRSF13B however is hindered by extreme polymorphism and by diversity of interactions of the protein. Nevertheless, TNFRSF13B variants have been found to exert distinct impact on natural and elicited antibody responses and host defense and mutations of TNFRSF13B have been found to influence the propensity for development of antibody-mediated rejection of organ transplants. Because B cell responses potentially limit application of xenotransplantation, understanding how TNFRSF13B diversity and TNFRSF13B variants govern immunity in xenotransplantation could inspire development of novel therapeutics that could in turn accelerate clinical implementation of xenotransplantation.
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Affiliation(s)
- Marilia Cascalho
- Department of Surgery and Department of Microbiology & Immunology, University of Michigan, Ann Arbor, MI, United States.
| | - Jeffrey L Platt
- Department of Surgery and Department of Microbiology & Immunology, University of Michigan, Ann Arbor, MI, United States.
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20
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Affiliation(s)
- Jay A Fishman
- From the Transplant and Immunocompromised Host Program, Infectious Disease Division and Transplant Center, Massachusetts General Hospital and Harvard Medical School, Boston
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21
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Choe YH, Sorensen J, Garry DJ, Garry MG. Blastocyst complementation and interspecies chimeras in gene edited pigs. Front Cell Dev Biol 2022; 10:1065536. [PMID: 36568986 PMCID: PMC9773398 DOI: 10.3389/fcell.2022.1065536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/17/2022] [Indexed: 12/13/2022] Open
Abstract
The only curative therapy for many endstage diseases is allograft organ transplantation. Due to the limited supply of donor organs, relatively few patients are recipients of a transplanted organ. Therefore, new strategies are warranted to address this unmet need. Using gene editing technologies, somatic cell nuclear transfer and human induced pluripotent stem cell technologies, interspecies chimeric organs have been pursued with promising results. In this review, we highlight the overall technical strategy, the successful early results and the hurdles that need to be addressed in order for these approaches to produce a successful organ that could be transplanted in patients with endstage diseases.
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Affiliation(s)
- Yong-ho Choe
- Lillehei Heart Institute, University of Minnesota, Minneapolis, MN, United States
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jacob Sorensen
- Lillehei Heart Institute, University of Minnesota, Minneapolis, MN, United States
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Daniel J. Garry
- Lillehei Heart Institute, University of Minnesota, Minneapolis, MN, United States
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States
- Paul and Sheila Wellstone Muscular Dystrophy Center, University of Minnesota, Minneapolis, MN, United States
| | - Mary G. Garry
- Lillehei Heart Institute, University of Minnesota, Minneapolis, MN, United States
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States
- Paul and Sheila Wellstone Muscular Dystrophy Center, University of Minnesota, Minneapolis, MN, United States
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22
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Nellore A, Walker J, Kahn MJ, Fishman JA. Moving xenotransplantation from bench to bedside: Managing infectious risk. Transpl Infect Dis 2022; 24:e13909. [PMID: 35870125 DOI: 10.1111/tid.13909] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 06/26/2022] [Accepted: 07/01/2022] [Indexed: 12/24/2022]
Abstract
Xenotransplantation of organs from swine in immunosuppressed human recipients poses many of the same challenges of allotransplantation relative to the risk for infection, malignancy, or graft rejection in proportion to the degree of immunosuppression and epidemiologic exposures. The unique features of xenotransplantation from pigs relative to infectious risk center on the potential for unusual organisms derived from swine causing productive infection, "xenosis" or "xenozoonosis," in the host. Based on experience in allotransplantation, the greatest hazard is due to viruses, due to the relative lack of information regarding the behavior of these potential pathogens in humans, the absence of validated serologic and molecular assays for swine-derived pathogens, and uncertainty regarding the efficacy of therapeutic agents for these organisms. Other known, potential pathogens (i.e., bacteria, fungi, parasites) tend to be comparable to those of humans. Concerns remain for unknown organisms in swine that may replicate in immunosuppressed humans. Clinical trials of genetically modified organs sourced from swine in immunosuppressed humans with organ failure are under development. Such trials require informed consent regarding potential infectious risks to the recipient, determination of breeding characteristics of swine, assessments of potential risks to the public and healthcare providers, consideration of ethical issues posed by this novel therapy, and defined strategies to monitor and address infectious episodes that may be encountered by healthcare teams. Clinical trials in xenotransplantation will allow improved definition of potential infectious risks.
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Affiliation(s)
- Anoma Nellore
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeremey Walker
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mauricio J Kahn
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jay A Fishman
- Division of Infectious Diseases and Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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23
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Sinagra G, Pagura L, Radesich C, Gagno G, Cannata’ A, Barbisan D, Cittar M, Paldino A, Perotto M, Mase’ M, Dal Ferro M, Mazzaro E, Merlo M. Cardiology of the future: xenotransplantation with porcine heart. Eur Heart J Suppl 2022; 24:I160-I164. [DOI: 10.1093/eurheartjsupp/suac107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
The reduced availability of human donor hearts compared with the needs of patients with advanced heart failure refractory to medical therapy has promoted the search for therapeutic alternatives to cardiac allografts. Porcine heart xenotransplantation represents one of the most promising frontiers in this field today. From the first researches in the 1960s to today, the numerous advances achieved in the field of surgical techniques, genetic engineering and immunosuppression have made it possible at the beginning of 2022 to carry out the first swine-to-human heart transplant, attaining a survival of 2 months after surgery. The main intellectual and experimental stages that have marked the history of xenotransplantation, the latest acquisitions in terms of genetic editing, as well as the improvement of immunosuppressive therapy are discussed analytically in this article in order to illustrate the underlying complexity of this therapeutic model.
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Affiliation(s)
- Gianfranco Sinagra
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
| | - Linda Pagura
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
- Cardiothoracovascular Department, Cardiac Surgery, Giuliano Isontina University Health Authority (ASUGI)
| | - Cinzia Radesich
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
| | - Giulia Gagno
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
| | - Antonio Cannata’
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
| | - Davide Barbisan
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
| | - Marco Cittar
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
| | - Alessia Paldino
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
| | - Maria Perotto
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
| | - Marco Mase’
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
| | - Matteo Dal Ferro
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
| | - Enzo Mazzaro
- Cardiothoracovascular Department, Cardiac Surgery, Giuliano Isontina University Health Authority (ASUGI)
| | - Marco Merlo
- Cardiothoracovascular Department, Cardiology, Giuliano Isontina University Health Authority (ASUGI), University of Trieste. European Reference Network for rare, low-prevalence, or complex diseases of the Heart (ERN GUARD-Heart)
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24
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Denner J, Schuurman HJ. Early testing of porcine organ xenotransplantation products in humans: Microbial safety as illustrated for porcine cytomegalovirus. Xenotransplantation 2022; 29:e12783. [PMID: 36336900 DOI: 10.1111/xen.12783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/20/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Joachim Denner
- Institute of Virology, Free University Berlin, Berlin, Germany
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25
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Chaban R, Habibabady Z, Hassanein W, Connolly MR, Burdorf L, Redding E, Laird C, Ranek J, Braileanu G, Sendil S, Cheng X, Sun W, O’Neill NA, Kuravi K, Hurh S, Ayares DL, Azimzadeh AM, Pierson RN. Knock-out of N-glycolylneuraminic acid attenuates antibody-mediated rejection in xenogenically perfused porcine lungs. Xenotransplantation 2022; 29:e12784. [PMID: 36250568 PMCID: PMC11093624 DOI: 10.1111/xen.12784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/27/2022] [Accepted: 09/13/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Antibody-mediated rejection has long been known to be one of the major organ failure mechanisms in xenotransplantation. In addition to the porcine α1,3-galactose (α1,3Gal) epitope, N-Glycolylneuraminic acid (Neu5Gc), a sialic acid, has been identified as an important porcine antigen against which most humans have pre-formed antibodies. Here we evaluate GalTKO.hCD46 lungs with an additional cytidine monophospho-N-acetylneuraminic acid hydroxylase (CMAH) gene knock-out (Neu5GcKO) in a xenogeneic ex vivo perfusion model METHODS: Eleven GalTKO.hCD46.Neu5GcKO pig lungs were perfused for up to 6 h with fresh heparinized human blood. Six of them were treated with histamine (H) blocker famotidine and 1-thromboxane synthase inhibitor Benzylimidazole (BIA) and five were left untreated. GalTKO.hCD46 lungs without Neu5GcKO (n = 18: eight untreated and 10 BIA+H treated) served as a reference. Functional parameters, blood, and tissue samples were collected at pre-defined time points throughout the perfusion RESULTS: All but one Neu5GcKO organs maintained adequate blood oxygenation and "survived" until elective termination at 6 h whereas two reference lungs failed before elective termination at 4 h. Human anti-Neu5Gc antibody serum levels decreased during the perfusion of GalTKO.hCD46 lungs by flow cytometry (∼40% IgM, 60% IgG), whereas antibody levels in Neu5GcKO lung perfusions did not fall (IgM p = .007; IgG p < .001). Thromboxane elaboration, thrombin generation, and histamine levels were significantly reduced with Neu5GcKO lungs compared to reference in the untreated groups (p = .007, .005, and .037, respectively); treatment with BIA+H masked these changes. Activation of platelets, measured as CD62P expression on circulating platelets, was lower in Neu5GcKO experiments compared to reference lungs (p = .023), whereas complement activation (as C3a rise in plasma) was not altered. MCP-1 and lactotransferin level elevations were blunted in Neu5GcKO lung perfusions (p = .007 and .032, respectively). Pulmonary vascular resistance (PVR) rise was significantly attenuated and delayed in untreated GalTKO.hCD46.Neu5GcKO lungs in comparison to the untreated GalTKO.hCD46 lungs (p = .003) CONCLUSION: Additional Neu5GcKO in GalTKO.hCD46 lungs significantly reduces parameters associated with antibody-mediated inflammation and activation of the coagulation cascade. Knock-out of the Neu5Gc sialic acid should be beneficial to reduce innate immune antigenicity of porcine lungs in future human recipients.
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Affiliation(s)
- Ryan Chaban
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Cardiovascular Surgery, University Hospital of Mainz, Mainz, Germany
| | - Zahra Habibabady
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Wessam Hassanein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Margaret R. Connolly
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lars Burdorf
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Revivicor, Inc., Blacksburg, Virgina, USA
| | - Emily Redding
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Christopher Laird
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jolene Ranek
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gheorghe Braileanu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Selin Sendil
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Xiangfei Cheng
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Natalie A. O’Neill
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Sunghoon Hurh
- Department of Biomedical Sciences, Korea University College of Medicine, Seoul, Korea
| | | | - Agnes M. Azimzadeh
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Richard N. Pierson
- Center for Transplantation Sciences and Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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26
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Garry DJ, Weiner JI, Greising SM, Garry MG, Sachs DH. Mechanisms and strategies to promote cardiac xenotransplantation. J Mol Cell Cardiol 2022; 172:109-119. [PMID: 36030840 DOI: 10.1016/j.yjmcc.2022.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/21/2022] [Accepted: 07/31/2022] [Indexed: 12/14/2022]
Abstract
End stage heart failure is a terminal disease, and the only curative therapy is orthotopic heart transplantation. Due to limited organ availability, alternative strategies have received intense interest for treatment of patients with advanced heart failure. Recent studies using gene-edited porcine organs suggest that cardiac xenotransplantation may provide a future source of organs. In this review, we highlight the historical milestones for cardiac xenotransplantation and the gene editing strategies designed to overcome immunological barriers, which have culminated in a recent cardiac pig-to-human xenotransplant. We also discuss recent results of studies on the engineering of human-porcine chimeric organs that may provide an alternative and complementary strategy to overcome some of the major immunological barriers to producing a new source of transplantable organs.
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Affiliation(s)
- Daniel J Garry
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States of America; Stem Cell Institute, University of Minnesota, Minneapolis, MN 55455, United States of America; Lillehei Heart Institute, University of Minnesota, Minneapolis, MN 55455, United States of America; NorthStar Genomics, Eagan, MN, United States of America.
| | - Joshua I Weiner
- Departments of Surgery, Columbia Center for Translational Immunology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States of America
| | - Sarah M Greising
- School of Kinesiology, University of Minnesota, Minneapolis, MN 55455, United States of America
| | - Mary G Garry
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States of America; Stem Cell Institute, University of Minnesota, Minneapolis, MN 55455, United States of America; Lillehei Heart Institute, University of Minnesota, Minneapolis, MN 55455, United States of America; NorthStar Genomics, Eagan, MN, United States of America
| | - David H Sachs
- Departments of Surgery, Columbia Center for Translational Immunology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States of America; Department of Surgery, Massachusetts General Hospital, Boston, MA, United States of America
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27
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Cimaroli S, Hines G. Cardiac Xenotransplantation: Where We Have Been and Where We Are Now. Cardiol Rev 2022; 30:279-280. [PMID: 35950947 DOI: 10.1097/crd.0000000000000474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Sawyer Cimaroli
- From the Department of Surgery, NYU Langone Long Island, Mineola, NY
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28
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Uzoigwe CE, Ali O. Genetically Modified Porcine-to-Human Cardiac Xenotransplantation. N Engl J Med 2022; 387:1337. [PMID: 36198188 DOI: 10.1056/nejmc2210401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Omer Ali
- Barts Health Trust, London, United Kingdom
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29
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Rogers MP, Fishberger G, Martini N, Baldwin M, Wang L, Chen W, Liu R, Lozonschi L. Orthotopic Heart Auto-Transplantation in a Swine Model. WORLD JOURNAL OF CARDIOVASCULAR SURGERY 2022; 12:200-206. [PMID: 36909676 PMCID: PMC10003613 DOI: 10.4236/wjcs.2022.129017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM The porcine heart bears the best resemblance to the human heart and remains the preferred preclinical model for anatomical, physiological, and medical device studies. In an effort to study phenomena related strictly to ischemia reperfusion and donor preservation protocols, it is essential to avoid the immune responses related to allotransplantation. Orthotopic auto-transplantation is a unique strategy to the field of cardiac transplantation for ex vivo experimentation. Nevertheless, auto-transplantation carries its own technical challenges related to insufficient length of the great vessels that are to be transected and re-anastomosed. METHODS A novel method for orthotopic cardiac auto-transplantation in the porcine model was developed and was described herein. Porcine models were used for ex vivo experimentation of a novel device to study ischemia reperfusion injury. RESULTS A total of five porcine models were used for ex vivo experimentation of a novel device to mitigate ischemia reperfusion injury and determine effects of donor preservation. Modifications to routine cardiac transplantation protocols to allow for successful auto-transplantation are described. CONCLUSION Orthotopic cardiac auto-transplantation in the porcine model is a plausible and technically feasible method for reliable study of ischemia reperfusion injury and donor preservation protocols. Here, we describe methods for both direct orthotopic porcine cardiac auto-transplantations as well as a simplified protocol that can be substituted for full surgical auto-transplantation for the studies of preservation of donor hearts.
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Affiliation(s)
- Michael P. Rogers
- Division of Cardiothoracic Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Gregory Fishberger
- Division of Cardiothoracic Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Nick Martini
- Division of Cardiothoracic Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Margaret Baldwin
- Department of Comparative Medicine, University of South Florida, Tampa, FL, USA
| | - Lei Wang
- Department of Molecular Pharmacology and Physiology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Wei Chen
- Department of Physics, College of Arts and Sciences, University of South Florida, Tampa, FL, USA
| | - Ruisheng Liu
- Department of Molecular Pharmacology and Physiology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Lucian Lozonschi
- Division of Cardiothoracic Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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30
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Pierson RN, Allan JS, Cooper DK, D’Alessandro DA, Fishman JA, Kawai T, Lewis GD, Madsen JC, Markmann JF, Riella LV. Expert Opinion Special Feature: Patient Selection for Initial Clinical Trials of Pig Organ Transplantation. Transplantation 2022; 106:1720-1723. [PMID: 35761442 PMCID: PMC10124765 DOI: 10.1097/tp.0000000000004197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Richard N. Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - James S. Allan
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - David K.C. Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - David A. D’Alessandro
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Jay A. Fishman
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Tatsuo Kawai
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Gregory D. Lewis
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Joren C. Madsen
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - James F. Markmann
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Leonardo V. Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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31
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Triposkiadis F, Giamouzis G, Kitai T, Skoularigis J, Starling RC, Xanthopoulos A. A Holistic View of Advanced Heart Failure. Life (Basel) 2022; 12:1298. [PMID: 36143336 PMCID: PMC9501910 DOI: 10.3390/life12091298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/08/2022] [Accepted: 08/21/2022] [Indexed: 01/12/2023] Open
Abstract
Advanced heart failure (HF) may occur at any level of left ventricular (LV) ejection fraction (LVEF). The latter, which is widely utilized for the evaluation of LV systolic performance and treatment guidance of HF patients, is heavily influenced by LV size and geometry. As the accurate evaluation of ventricular systolic function and size is crucial in patients with advanced HF, the LVEF should be supplemented or even replaced by more specific indices of LV function such as the systolic strain and cardiac power output and size such as the LV diastolic diameters and volumes. Conventional treatment (cause eradication, medications, devices) is often poorly tolerated and fails and advanced treatment (mechanical circulatory support [MCS], heart transplantation [HTx]) is required. The effectiveness of MCS is heavily dependent on heart size, whereas HTx which is effective in the vast majority of the cases is limited by the small donor pool. Expanding the MCS indications to include patients with small ventricles as well as the HTx donor pool are major challenges in the management of advanced HF.
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Affiliation(s)
| | - Grigorios Giamouzis
- Department of Cardiology, University Hospital of Larissa, 411 10 Larissa, Greece
| | - Takeshi Kitai
- National Cerebral and Cardiovascular Center, Osaka 564-8565, Japan
| | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 411 10 Larissa, Greece
| | - Randall C. Starling
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland, OH 44195, USA
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 411 10 Larissa, Greece
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32
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Chaban R, Cooper DKC, Pierson RN. Pig heart and lung xenotransplantation: Present status. J Heart Lung Transplant 2022; 41:1014-1022. [PMID: 35659792 PMCID: PMC10124776 DOI: 10.1016/j.healun.2022.04.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/14/2022] [Accepted: 04/24/2022] [Indexed: 11/19/2022] Open
Abstract
The recent pig heart transplant in a patient at the University of Maryland Medical Center has stimulated renewed interest in the xenotransplantation of organs from genetically engineered pigs. The barriers to the use of pigs as sources of organs have largely been overcome by 2 approaches - (1) the deletion of expression of the three known pig carbohydrate xenoantigens against which humans have preformed antibodies, and (2) the transgenic introduction of human 'protective' proteins, such as complement-regulatory proteins. These gene modifications, coupled with immunosuppressive therapy based on blockade of the CD40/CD154 costimulation pathway, have resulted in survival of baboons with life-supporting pig heart grafts for almost 9 months. The initial clinical success at the University of Maryland reinforces encouraging preclinical results. It suggests that pig hearts are likely to provide an effective bridge to an allotransplant, but their utility for destination therapy remains uncertain. Because of additional complex immunobiological problems, the same approach has been less successful in preclinical lung xenograft transplantation, where survival is still measured in days or weeks. The first formal clinical trials of pig heart transplantation may include patients who do not have access to an allotransplant, those with contraindications for mechanical circulatory support, those in need of retransplantation or with a high level of panel-reactive antibodies. Infants with complex congenital heart disease, should also be considered.
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Affiliation(s)
- Ryan Chaban
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Cardiovascular Surgery, University Hospital of Johannes Gutenberg University, Mainz, Germany.
| | - David K C Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Richard N Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Kavarana S, Kwon JH, Zilinskas K, Kang L, Turek JW, Mohiuddin MM, Rajab TK. Recent advances in porcine cardiac xenotransplantation: from aortic valve replacement to heart transplantation. Expert Rev Cardiovasc Ther 2022; 20:597-608. [PMID: 35818712 DOI: 10.1080/14779072.2022.2100760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Cardiac xenotransplantation presents significant potential to the field of heart failure by addressing the high demand for donor organs. The availability of xenograft hearts would substantially augment the number of life-saving organs available to patients and may ultimately liberalize eligibility criteria for transplantation. AREAS COVERED In this review, we will discuss the need for cardiac xenotransplantation and the history of research and clinical practice in this field. Specifically, we address immunologic concepts and clinical lessons learned from heart valve replacement using xenogeneic tissues, the advancement of xenotransplantation using organs from genetically modified animals, and the progression of this research to the first-in-man pig-to-human heart transplantation. EXPERT OPINION Cardiac xenotransplantation holds tremendous promise, but the indications for this new treatment will need to be clearly defined because mechanical support with ventricular assist devices and total artificial hearts are increasingly successful alternatives for adults in heart failure. Cardiac xenotransplantation will also serve as temporary bridge to allotransplantation in babies with complex congenital heart disease who are too small for the currently available mechanical assist devices. Moreover, xenotransplantation of the part of the heart containing a heart valve could deliver growing heart valve implants for babies with severe heart valve dysfunction.
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Carrier AN, Verma A, Mohiuddin M, Pascual M, Muller YD, Longchamp A, Bhati C, Buhler LH, Maluf DG, Meier RPH. Xenotransplantation: A New Era. Front Immunol 2022; 13:900594. [PMID: 35757701 PMCID: PMC9218200 DOI: 10.3389/fimmu.2022.900594] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Organ allotransplantation has now reached an impassable ceiling inherent to the limited supply of human donor organs. In the United States, there are currently over 100,000 individuals on the national transplant waiting list awaiting a kidney, heart, and/or liver transplant. This is in contrast with only a fraction of them receiving a living or deceased donor allograft. Given the morbidity, mortality, costs, or absence of supportive treatments, xenotransplant has the potential to address the critical shortage in organ grafts. Last decade research efforts focused on creation of donor organs from pigs with various genes edited out using CRISPR technologies and utilizing non-human primates for trial. Three groups in the United States have recently moved forward with trials in human subjects and obtained initial successful results with pig-to-human heart and kidney xenotransplantation. This review serves as a brief discussion of the recent progress in xenotransplantation research, particularly as it concerns utilization of porcine heart, renal, and liver xenografts in clinical practice.
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Affiliation(s)
- Amber N Carrier
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Anjali Verma
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Muhammad Mohiuddin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Manuel Pascual
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Yannick D Muller
- Division of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Alban Longchamp
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Chandra Bhati
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Leo H Buhler
- Faculty of Science and Medicine, Section of Medicine, University of Fribourg, Fribourg, Switzerland
| | - Daniel G Maluf
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Raphael P H Meier
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
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Abstract
Heart transplantation (HTx) has a storied past, with origins dating back to the early twentieth century and the first pediatric orthotopic heart transplant performed in 1967 on a neonate with Ebstein abnormality. Today, approximately 500 pediatric HTx are performed annually, with survival times now measured in decades rather than days or weeks. In large part, advances in immunosuppression, critical care, dedicated transplant teams and mechanical circulatory support have paved the way for improvements in waitlist mortality and post-transplant survival, with future directions including the development of intracorporeal ventricular assist devices (VADs) for small children, expanding/standardizing donor criteria, and xenotransplantation.
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Affiliation(s)
- Richard N Pierson
- From the Division of Cardiac Surgery, Department of Surgery, and the Center for Transplantation Sciences, Massachusetts General Hospital, and Harvard Medical School - both in Boston
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Affiliation(s)
- Bin Q. Yang
- Division of Cardiology, Department of Internal Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Arick C. Park
- Division of Cardiology, Department of Internal Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joel D. Schilling
- Division of Cardiology, Department of Internal Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Immunology and Pathology, Washington University in St. Louis, St. Louis, Missouri, USA
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38
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Signaling cascades in the failing heart and emerging therapeutic strategies. Signal Transduct Target Ther 2022; 7:134. [PMID: 35461308 PMCID: PMC9035186 DOI: 10.1038/s41392-022-00972-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/13/2022] [Accepted: 03/20/2022] [Indexed: 12/11/2022] Open
Abstract
Chronic heart failure is the end stage of cardiac diseases. With a high prevalence and a high mortality rate worldwide, chronic heart failure is one of the heaviest health-related burdens. In addition to the standard neurohormonal blockade therapy, several medications have been developed for chronic heart failure treatment, but the population-wide improvement in chronic heart failure prognosis over time has been modest, and novel therapies are still needed. Mechanistic discovery and technical innovation are powerful driving forces for therapeutic development. On the one hand, the past decades have witnessed great progress in understanding the mechanism of chronic heart failure. It is now known that chronic heart failure is not only a matter involving cardiomyocytes. Instead, chronic heart failure involves numerous signaling pathways in noncardiomyocytes, including fibroblasts, immune cells, vascular cells, and lymphatic endothelial cells, and crosstalk among these cells. The complex regulatory network includes protein-protein, protein-RNA, and RNA-RNA interactions. These achievements in mechanistic studies provide novel insights for future therapeutic targets. On the other hand, with the development of modern biological techniques, targeting a protein pharmacologically is no longer the sole option for treating chronic heart failure. Gene therapy can directly manipulate the expression level of genes; gene editing techniques provide hope for curing hereditary cardiomyopathy; cell therapy aims to replace dysfunctional cardiomyocytes; and xenotransplantation may solve the problem of donor heart shortages. In this paper, we reviewed these two aspects in the field of failing heart signaling cascades and emerging therapeutic strategies based on modern biological techniques.
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Miyagawa S, Maeda A, Toyama C, Kogata S, Okamatsu C, Yamamoto R, Masahata K, Kamiyama M, Eguchi H, Watanabe M, Nagashima H, Ikawa M, Matsunami K, Okuyama H. Aspects of the Complement System in New Era of Xenotransplantation. Front Immunol 2022; 13:860165. [PMID: 35493484 PMCID: PMC9046582 DOI: 10.3389/fimmu.2022.860165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/07/2022] [Indexed: 01/16/2023] Open
Abstract
After producing triple (Gal, H-D and Sda)-KO pigs, hyperacute rejection appeared to no longer be a problem. However, the origin of xeno-rejection continues to be a controversial topic, including small amounts of antibodies and subsequent activation of the graft endothelium, the complement recognition system and the coagulation systems. The complement is activated via the classical pathway by non-Gal/H-D/Sda antigens and by ischemia-reperfusion injury (IRI), via the alternative pathway, especially on islets, and via the lectin pathway. The complement system therefore is still an important recognition and effector mechanism in xeno-rejection. All complement regulatory proteins (CRPs) regulate complement activation in different manners. Therefore, to effectively protect xenografts against xeno-rejection, it would appear reasonable to employ not only one but several CRPs including anti-complement drugs. The further assessment of antigens continues to be an important issue in the area of clinical xenotransplantation. The above conclusions suggest that the expression of sufficient levels of human CRPs on Triple-KO grafts is necessary. Moreover, multilateral inhibition on local complement activation in the graft, together with the control of signals between macrophages and lymphocytes is required.
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Affiliation(s)
- Shuji Miyagawa
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
- International Institute for Bio-Resource Research, Meiji University, Kanagawa, Japan
- Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
- *Correspondence: Shuji Miyagawa,
| | - Akira Maeda
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Chiyoshi Toyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Kogata
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Chizu Okamatsu
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Riho Yamamoto
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazunori Masahata
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masafumi Kamiyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Eguchi
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masahito Watanabe
- International Institute for Bio-Resource Research, Meiji University, Kanagawa, Japan
| | - Hiroshi Nagashima
- International Institute for Bio-Resource Research, Meiji University, Kanagawa, Japan
| | - Masahito Ikawa
- Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Katsuyoshi Matsunami
- Department of Pharmacognosy, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Strauss ER, Odonkor PN, Williams B. Porcine Orthotopic Cardiac Xenotransplantation: The Role and Perspective of Anesthesiologists. J Cardiothorac Vasc Anesth 2022; 36:2847-2850. [DOI: 10.1053/j.jvca.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/03/2022] [Indexed: 11/11/2022]
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41
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DeFilippis EM, Khush KK, Farr MA, Fiedler A, Kilic A, Givertz MM. Evolving Characteristics of Heart Transplantation Donors and Recipients: JACC Focus Seminar. J Am Coll Cardiol 2022; 79:1108-1123. [PMID: 35300823 DOI: 10.1016/j.jacc.2021.11.064] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/08/2021] [Accepted: 11/22/2021] [Indexed: 12/22/2022]
Abstract
Although the burden of end-stage heart failure continues to increase, the number of available organs for heart transplantation (HT) remains inadequate. The HT community has been challenged to find ways to expand the number of donor hearts available. Recent advances include use of hearts from donors infected with hepatitis C virus as well as other previously underutilized donors, including those with left ventricular dysfunction, of older age, and with a history of cocaine use. Concurrently, emerging trends in HT surgery include donation after circulatory death, ex vivo normothermic heart perfusion, and controlled hypothermic preservation, which may enable procurement of organs from farther distances and prevent early allograft dysfunction. Contemporary HT recipients have also evolved in light of the 2018 revision to the U.S. heart allocation policy. This focus seminar discusses recent trends in donor and recipient phenotypes and management strategies for successful HT, as well as evolving areas and future directions.
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Affiliation(s)
| | - Kiran K Khush
- Stanford University Medical Center, Stanford, California, USA
| | | | - Amy Fiedler
- University of Wisconsin Hospitals, Madison, Wisconsin, USA
| | - Arman Kilic
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael M Givertz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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42
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Affiliation(s)
- Maryjane A Farr
- Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT
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43
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Mehra MR. Cardiac Xenotransplantation: Rebirth Amidst An Uncertain Future. J Card Fail 2022; 28:873-874. [DOI: 10.1016/j.cardfail.2022.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 12/31/2022]
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44
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Cozzi E, Schneeberger S, Bellini MI, Berglund E, Böhmig G, Fowler K, Hoogduijn M, Jochmans I, Marckmann G, Marson L, Neuberger J, Oberbauer R, Pierson RN, Reichart B, Scobie L, White C, Naesens M. Organ transplants of the future: planning for innovations including xenotransplantation. Transpl Int 2021; 34:2006-2018. [PMID: 34459040 DOI: 10.1111/tri.14031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/10/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022]
Abstract
The future clinical application of animal-to-human transplantation (xenotransplantation) is of importance to society as a whole. Favourable preclinical data relevant to cell, tissue and solid organ xenotransplants have been obtained from many animal models utilizing genetic engineering and protocols of pathogen-free husbandry. Findings have reached a tipping point, and xenotransplantation of solid organs is approaching clinical evaluation, the process of which now requires close deliberation. Such discussions include considering when there is sufficient evidence from preclinical animal studies to start first-in-human xenotransplantation trials. The present article is based on evidence and opinions formulated by members of the European Society for Organ Transplantation who are involved in the Transplantation Learning Journey project. The article includes a brief overview of preclinical concepts and biology of solid organ xenotransplantation, discusses the selection of candidates for first-in-human studies and considers requirements for study design and conduct. In addition, the paper emphasizes the need for a regulatory framework for xenotransplantation of solid organs and the essential requirement for input from public and patient stakeholders.
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Affiliation(s)
- Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Transplant Immunology Unit, Padua University Hospital, Padua, Italy
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Maria Irene Bellini
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
- Department of Emergency Medicine and Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Erik Berglund
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska Institute and ITB-MED, Stockholm, Sweden
| | - Georg Böhmig
- Division of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | - Kevin Fowler
- The Voice of the Patient, Inc., Chicago, IL, USA
| | - Martin Hoogduijn
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lorna Marson
- The Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Richard N Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Bruno Reichart
- Walter Brendel Center for Experimental Medicine, LMU Munich, Munich, Germany
| | - Linda Scobie
- Department of Biological and Biomedical Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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45
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Guidetti F, Arrigo M, Frank M, Mikulicic F, Sokolski M, Aser R, Wilhelm MJ, Flammer AJ, Ruschitzka F, Winnik S. Treatment of Advanced Heart Failure-Focus on Transplantation and Durable Mechanical Circulatory Support: What Does the Future Hold? Heart Fail Clin 2021; 17:697-708. [PMID: 34511216 DOI: 10.1016/j.hfc.2021.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Heart transplantation (HTx) is the treatment of choice in patients with late-stage advanced heart failure (Advanced HF). Survival rates 1, 5, and 10 years after transplantation are 87%, 77%, and 57%, respectively, and the average life expectancy is 9.16 years. However, because of the donor organ shortage, waiting times often exceed life expectancy, resulting in a waiting list mortality of around 20%. This review aims to provide an overview of current standard, recent advances, and future developments in the treatment of Advanced HF with a focus on long-term mechanical circulatory support and HTx.
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Affiliation(s)
- Federica Guidetti
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland.
| | - Mattia Arrigo
- Department of Internal Medicine, Triemli Hospital Zürich, Birmensdorferstrasse 497, 8063 Zürich, Switzerland
| | - Michelle Frank
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Fran Mikulicic
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Mateusz Sokolski
- Department of Heart Diseases, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Raed Aser
- Department of Cardiac Surgery, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Markus J Wilhelm
- Department of Cardiac Surgery, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Andreas J Flammer
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
| | - Stephan Winnik
- Department of Cardiology, University Hospital of Zürich, Rämistrasse 100, Zürich 8091, Switzerland
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46
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Loebe M, Parker B. Don't pig(!) the wrong heart! J Card Surg 2021; 36:3802-3804. [PMID: 34309898 DOI: 10.1111/jocs.15842] [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: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 11/29/2022]
Abstract
Cardiac xenotransplantation is believed to have approached clinical application. However, this approach to advanced heart failure is burdened with a multitude of ethical issues. These issues need to be addressed openly and be broadly discussed in public. Only through an honest and transparent approach, it will be possible to engage the lay audience in the evaluation of pig to human transplant.
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Affiliation(s)
- Matthias Loebe
- Department of Surgery, University of Miami, Miami, Florida, USA
| | - Brandon Parker
- Department of Surgery, University of Miami, Miami, Florida, USA
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47
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Garcia LR, Brito FDS, Felicio ML, Garzesi AM, Tardivo MT, Polegato BF, Minicucci MF, Zornoff LAM. Clinical trials in cardiac xenotransplantation: Are we ready to overcome barriers? J Card Surg 2021; 36:3796-3801. [PMID: 34137071 DOI: 10.1111/jocs.15747] [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: 04/15/2021] [Revised: 05/25/2021] [Accepted: 06/10/2021] [Indexed: 11/28/2022]
Abstract
Heart allotransplantation has become one of the methods of choice in the treatment of severe heart failure. In the face of its difficulties, such as the unmet balance between organ supply and demand, the use of xenotransplantation (XTx) might be an attractive option shortly, even more with the ongoing progress achieved regarding the avoidance of hyperacute rejection and primary organ disfunction, maintenance of xenograft function and control of xenograft growth. To make possible this translational challenge, some points must be taken into account indeed, and they are the equipoise of human benefit and animal suffering, the risk of unknown infections, a well prepared informed consent, ethical and religious beliefs, and the role of cardiac XTx in a ventricular assistance device era.
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Affiliation(s)
- Leonardo Rufino Garcia
- Department of Surgery, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - Flavio de Souza Brito
- Department of Surgery, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - Marcello Laneza Felicio
- Department of Surgery, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - André Monti Garzesi
- Department of Surgery, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - Márcia Terezinha Tardivo
- Department of Internal Medicine, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - Bertha Furlan Polegato
- Department of Internal Medicine, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - Marcos Ferreira Minicucci
- Department of Internal Medicine, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
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48
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Rajab TK, Mohiuddin MM, Kavarana MN. Xenotransplantation Is the Future of Pediatric Cardiac Surgery…. Ann Thorac Surg 2021; 114:544. [PMID: 34102181 DOI: 10.1016/j.athoracsur.2021.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 05/23/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Taufiek Konrad Rajab
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Muhammad M Mohiuddin
- Director, Cardiac Xenotransplantation Program, University of Maryland School of Medicine, Baltimore, MD
| | - Minoo N Kavarana
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, 10 McClennan Banks Drive, Charleston, SC, 29425.
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49
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Affiliation(s)
- Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,Department of Cardiothoracic Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Germany.,Department of Health Sciences, ETH Zurich, Translational Cardiovascular Technologies, Switzerland
| | - Maximilian Y Emmert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,Department of Cardiothoracic Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Germany.,Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
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50
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Pierson RN, Hawthorne WJ. Agnès Marie Azimzadeh, Ph.D – “In Memoriam”. Xenotransplantation 2021. [DOI: 10.1111/xen.12689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Richard N. Pierson
- Department of Surgery Massachusetts General Hospital and Harvard Medical School Boston MA USA
- Center for Transplantation Sciences Massachusetts General Hospital Boston MA USA
| | - Wayne J. Hawthorne
- Centre for Transplant and Renal Research The Westmead Institute for Medical Research Westmead Hospital Sydney NSW Australia
- Department of Surgery Western Clinical School University of Sydney Sydney NSW Australia
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