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Wells MA, See Hoe LE, Heather LC, Molenaar P, Suen JY, Peart J, McGiffin D, Fraser JF. Peritransplant Cardiometabolic and Mitochondrial Function: The Missing Piece in Donor Heart Dysfunction and Graft Failure. Transplantation 2021; 105:496-508. [PMID: 33617201 DOI: 10.1097/tp.0000000000003368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Primary graft dysfunction is an important cause of morbidity and mortality after cardiac transplantation. Donor brain stem death (BSD) is a significant contributor to donor heart dysfunction and primary graft dysfunction. There remain substantial gaps in the mechanistic understanding of peritransplant cardiac dysfunction. One of these gaps is cardiac metabolism and metabolic function. The healthy heart is an "omnivore," capable of utilizing multiple sources of nutrients to fuel its enormous energetic demand. When this fails, metabolic inflexibility leads to myocardial dysfunction. Data have hinted at metabolic disturbance in the BSD donor and subsequent heart transplantation; however, there is limited evidence demonstrating specific metabolic or mitochondrial dysfunction. This review will examine the literature surrounding cardiometabolic and mitochondrial function in the BSD donor, organ preservation, and subsequent cardiac transplantation. A more comprehensive understanding of this subject may then help to identify important cardioprotective strategies to improve the number and quality of donor hearts.
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Affiliation(s)
- Matthew A Wells
- School of medical Science, Griffith University Gold Coast, Australia
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Australia
| | - Louise E See Hoe
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Australia
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, St Lucia, Australia
| | - Lisa C Heather
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Peter Molenaar
- Faculty of Health, School of Biomedical Sciences, Queensland University of Technology, Brisbane City, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Australia
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, St Lucia, Australia
| | - Jason Peart
- School of medical Science, Griffith University Gold Coast, Australia
| | - David McGiffin
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Australia
- Cardiothoracic Surgery and Transplantation, The Alfred Hospital, Melbourne, Australia
| | - John F Fraser
- School of medical Science, Griffith University Gold Coast, Australia
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Australia
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, St Lucia, Australia
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Arab D, Yahia AM, Qureshi AI. Cardiovascular Manifestations of Acute Intracranial Lesions: Pathophysiology, Manifestations, and Treatment. J Intensive Care Med 2016; 18:119-29. [PMID: 14984630 DOI: 10.1177/0885066603251202] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this article was to review the effects of acute intracranial lesions on myocardial function. The authors reviewed scientific and clinical literature retrieved from a computerized MEDLINE search from January 1965 through January 2002. Pertinent literature was referenced, including clinical and laboratory investigations, to demonstrate the effects of acute intracranial lesions on the cardiovascular system. The literature was reviewed to summarize the mechanisms of cardiac damage and clinical manifestations and treatment of cardiovascular dysfunction caused by acute intracranial lesions. Myocardial damage and rhythm disturbances were shown to occur with acute intracranial neurological disease. The subgroup of patients used in this study formed a substantial pool of cardiac donors for cardiac transplantation. The pathophysiology of myocardial dysfunction and the optimal management continues to be a source of debate. In this article, the authors will review the anatomy, the available evidence of the pathophysiology, and the management of this complex group of patients. They will also discuss areas that need to be further investigated. Cardiovascular effects of acute intracranial lesions are common and contribute to increased morbidity and mortality.
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Affiliation(s)
- Dinesh Arab
- Department of Medicine, Division of Cardiology, Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo 14209-1194, USA
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Silva I, Correia C, Simas R, Correia C, Cruz J, Ferreira S, Zanoni F, Menegat L, Sannomiya P, Moreira L. Inhibition of Autonomic Storm by Epidural Anesthesia Does Not Influence Cardiac Inflammatory Response After Brain Death in Rats. Transplant Proc 2012; 44:2213-8. [DOI: 10.1016/j.transproceed.2012.07.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The clinical importance of cardiovascular consequences resulting from cerebral injury has long been recognized. However, interactions between the brain and the cardiovascular system remain poorly defined and their importance for the management of patients suffering from acute brain injury is largely underestimated. This should have profound consequences on treatment strategies during anaesthesia and intensive cares of these patients, taking into account not only brain perfusion, but also cardiovascular optimisation. This report summarizes the main data available regarding the cardiovascular consequences of brain death, traumatic brain injury, stroke and epilepsy.
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Affiliation(s)
- P-M Mertes
- Service d'anesthésie-réanimation, CHU de Nancy, hôpital Central, 29, avenue de Lattre-de-Tassigny, 54035 Nancy cedex, France.
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Bombardini T, Gherardi S, Arpesella G, Maccherini M, Serra W, Magnani G, Del Bene R, Picano E. Favorable short-term outcome of transplanted hearts selected from marginal donors by pharmacological stress echocardiography. J Am Soc Echocardiogr 2011; 24:353-62. [PMID: 21440213 DOI: 10.1016/j.echo.2010.11.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2010] [Indexed: 12/29/2022]
Abstract
BACKGROUND Because of the shortage of donor hearts, the criteria for acceptance have been considerably expanded. Abnormal results on pharmacologic stress echocardiography are associated with significant coronary artery disease and/or occult cardiomyopathy on verification by cardiac autopsy. The aim of this study was to establish the feasibility of an approach based on pharmacologic stress echocardiography as a gatekeeper for extended heart donor criteria. METHODS From April 2005 to April 2010, 39 "marginal" candidate donors (mean age, 56 ± 6 years; 21 men) were initially enrolled. After legal declaration of brain death, marginal donors underwent rest echocardiography, and if the results were normal, dipyridamole (0.84 mg/kg over 6 min, n = 25) or dobutamine (up to 40 μg/kg/min, n = 3) stress echocardiography. RESULTS A total of 19 eligible hearts were found with normal findings. Of these, three were not transplanted because of the lack of a matching recipient, and verification by cardiac autopsy showed absence of significant coronary artery disease or cardiomyopathy abnormalities. The remaining 16 eligible hearts were uneventfully transplanted in marginal emergency recipients. All showed normal (n = 14) or nearly normal (minor single-vessel disease in two) angiographic, intravascular ultrasound, hemodynamic and ventriculographic findings at 1 month. At follow-up (median, 14 months; interquartile range, 4-31 months), 14 patients survived and two had died, one at 2 months from general sepsis and one at 32 months from allograft vasculopathy in recurrent multiple myeloma. CONCLUSIONS Pharmacologic stress echocardiography can safely be performed in candidate heart donors with brain death and shows potential for extending donor criteria in heart transplantation.
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Affiliation(s)
- Tonino Bombardini
- Institute of Clinical Physiology, National Research Council, Pisa, Italy.
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Nakagawa K, Tang JF. Physiologic response of human brain death and the use of vasopressin for successful organ transplantation. J Clin Anesth 2011; 23:145-8. [DOI: 10.1016/j.jclinane.2009.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 11/13/2009] [Accepted: 12/14/2009] [Indexed: 10/18/2022]
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Contribution of Toll-like receptor activation to lung damage after donor brain death. Transplantation 2010; 90:732-9. [PMID: 20671596 DOI: 10.1097/tp.0b013e3181eefe02] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Donor brain death is the first injurious event that can produce inflammatory dysfunction after pulmonary transplantation. This study was designed to determine whether stimulation of the toll-like receptor (TLR) system contributes to the changes produced by brain death. MATERIALS AND METHODS Rats were repeatedly treated with specific agonists for TLR4 or TLR2/6 to desensitize these receptors. Brain death was then induced by inflation of a balloon catheter within the extradural space. Mean arterial pressure changes and inflammatory markers were measured serially by protein and mRNA analysis. RESULTS Both desensitizing pretreatments prevented the neurogenic hypotension (P<0.001) and metabolic acidosis (P<0.001) observed in control animals after brain death. These treatments also reduced the levels of tumor necrosis factor-α and CXCL1 in serum and bronchoalveolar lavage fluid, although desensitization of TLR4 produced a greater inhibition than desensitization of TLR2. Desensitization of TLR4 also reduced (P<0.05) expression of the adhesive integrin CD11b on blood neutrophils after brain death. Examination of mRNA levels in lung tissue 5 hr after brain death showed that desensitization of TLR4 limited the expression of interferon (IFN)-γ, IFNβ, and CXCL10, whereas desensitization of TLR2/6 reduced only the expression of IFNγ. CONCLUSION These results indicate that activation of TLR signaling pathways can contribute to the lung damage produced by brain death; this may increase subsequent graft injury after transplantation.
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Abstract
What is the successful cardiopulmonary resuscitation? It is the few minutes postcardiopulmonary arrest that can answer. Twenty to 40 percent of patients who sustained cardiac arrest are initially resuscitated, but only 10% survive to hospital discharge, and more than 60% of victims succumb within 24 hours. This high fatality rate in the early hours and days after successful resuscitation is mainly related to the acute, intense, and reversible form of postresuscitation myocardial dysfunction (stunning) together with the ventricular tachyarrhythmia. It is a reversible process, provided that we are aware of the pertinent pathophysiology and then intervene accordingly. Herein I reviewed most of the published relevant articles concerning the causes, underlying mechanism, and the updated trials for management of postresuscitation myocardial stunning. I do agree that not only the restoration of the circulation but also long-term outcome should be the aim of resuscitation, and I readdress the role of epinephrine, dobutamine, biphasic defibrillator, with the new promising agent (ie, potassium channel opener), Delta-opioid receptor agonist, unloading intracellular calcium, antioxidants, and therapeutic hypothermia to halt this period of stunning. This will improve the outcome of the resuscitation efforts.
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Hing AJ, Hicks M, Garlick SR, Gao L, Kesteven SH, Faddy SC, Wilson MK, Feneley MP, Macdonald PS. The effects of hormone resuscitation on cardiac function and hemodynamics in a porcine brain-dead organ donor model. Am J Transplant 2007; 7:809-17. [PMID: 17331116 DOI: 10.1111/j.1600-6143.2007.01735.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We compared the effects of hormone resuscitation (HR) with a norepinephrine-based protocol on cardiac function, hemodynamics and need for vasopressor support after brain death in a porcine model. Following brain death induction, animals were treated with norepinephrine and fluids for 3 h. In the following 3 h, they continued on norepinephrine and fluids (control) or received additional HR (triiodothyronine, methylprednisolone, vasopressin, insulin). Data were collected pre-brain death, 3 and 6 h post-brain death. At 6 h, median norepinephrine use was higher in controls (0.563 vs. 0 microg/kg/min; p < 0.005), with 6/8 HR animals weaned off norepinephrine compared with 0/9 controls. Mean arterial pressure was higher in HR animals at 6 h (74 +/- 17 vs. 54 +/- 14 mmHg; p < 0.05). Cardiac contractility was also significantly higher in HR animals at 6 h (stroke work index 1.777 vs. 1.494). After collection of 6 h data, all animals were placed on the same low dose of norepinephrine. At 6.25 h, HR animals had higher stroke work (3540 +/- 1083 vs. 1536 +/- 702 mL.mmHg; p < 0.005), stroke volume (37.2 +/- 8.2 vs. 21.5 +/- 9.8 mL; p < 0.01) and cardiac output (5.8 +/- 1.4 vs. 3.2 +/- 1.2 L/min; p < 0.005). HR in a porcine model of brain death reduces norepinephrine requirements, and improves hemodynamics and cardiac function. These results support the use of HR in the management of the brain-dead donor.
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Affiliation(s)
- A J Hing
- Transplant Program, The Victor Chang Cardiac Research Institute, and Heart Transplant Unit, St Vincent's Hospital, Sydney, Australia.
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Li J, Konstantinov IE, Cai S, Shimizu M, Redington AN. Systemic and Myocardial Oxygen Transport Responses to Brain Death in Pigs. Transplant Proc 2007; 39:21-6. [PMID: 17275467 DOI: 10.1016/j.transproceed.2006.10.201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Brain death is associated with profound disturbances of systemic and myocardial oxygen transport, but little is known regarding the acute response of systemic oxygen consumption (VO(2)). METHODS Brain death was induced in 6 pigs (30.6 +/- 3.0 kg) by balloon inflation into the cranial cavity. VO(2) was continuously measured by respiratory mass spectrometry. Blood pressures and gases were measured from the aorta, superior vena cava, and coronary sinus, with arterial epinephrine and norepinephrine, prior to brain death, at 1, 10, and 90 minutes after brain death. Cardiac output (CO), systemic vascular resistance (SVR), oxygen delivery (DO(2)), oxygen extraction (EO(2)), and myocardial oxygen (mEO(2)) and lactate extractions (mE(1ac)) were calculated. Left ventricular contractility was assessed by micromanometer tipped catheters. RESULTS VO(2) increased from 4.8 +/- 0.9 to 6.3 +/- 0.9 mL/min/kg 1 minute after brain death (P < .001), and subsequently decreased to below baseline at 90 minutes (P < .001). Left ventricular contractility, CO, and DO(2) increased 1 minute after brain death (P < .001), followed by a rapid decrease to baseline within 10 minutes (P < .001). SVR and EO(2) decreased after brain death (P < .01) and remained low. Lactate remained unchanged. mE(1ac) decreased after brain death despite a decrease in mEO(2) (P < .01), and returned to baseline at 90 minutes. CONCLUSIONS The initial surge in VO(2) after brain death is offset by the greater increase in DO(2), thus tissue perfusion remains adequate. The lower than baseline VO(2) and SVR at the end of the study period may indicate general metabolic and hemodynamic compromise. The information regarding the profound metabolic alterations imposed by brain death may have implications for management of brain death donors.
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Affiliation(s)
- J Li
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Ferrera R, Bopassa JC, Rodriguez C, Baverel G, Ovize M. A simple and reliable method to assess heart viability after hypothermic procurement. Transplant Proc 2006; 38:2283-4. [PMID: 16980065 DOI: 10.1016/j.transproceed.2006.06.124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Hearts from brain dead pigs (n = 18) were submitted to 0 (group I), 10 (group II), or 20 (group III) minutes of in situ warm ischemia (animal exsanguination). After harvesting, cold cardioplegia solution was perfused in retrograde fashion and initial coronary flow (ICF) measured. After left ventricular energetic indices were measured using NMR spectroscopy, the hearts were transplanted orthotopically. Follow-up was performed over 120 minutes after cardiopulmonary bypass. We observed a progressive decrease in ICF with increased warm ischemia times: 50 +/- 3.4 mL/min per 100 g of tissue in the group I, 36 +/- 7 and 30 +/- 3.5 in groups II and III, respectively (P < .05 and P < .01 versus group I). The ICF strongly correlated with the energetic index (r = 0.76, P < .001) and with posttransplant function of the transplanted heart. These data showed that measurement of initial coronary flow after cardioplegia was a reliable test to evaluate cardiac graft viability before transplantation.
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Affiliation(s)
- R Ferrera
- INSERM EMI-U 0226, Laboratoire de Physiologie, Faculté de médecine Lyon-Nord, 8 avenue Rockefeller, 69373 Lyon Cedex 08, France.
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Audibert G, Charpentier C, Seguin-Devaux C, Charretier PA, Grégoire H, Devaux Y, Perrier JF, Longrois D, Mertes PM. Improvement of Donor Myocardial Function after Treatment of Autonomic Storm During Brain Death. Transplantation 2006; 82:1031-6. [PMID: 17060850 DOI: 10.1097/01.tp.0000235825.97538.d5] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In experimental brain death models, autonomic storm (AS) triggers severe myocardial dysfunction, which can be attenuated by pharmacologic treatment. The aim of this study was to determine the incidence of AS in a cohort of human organ donors and to evaluate the potential interest of AS treatment on myocardial function, cardiac harvesting and transplantation. METHODS The cohort consisted of 152 patients. Among them, 46 patients were initially considered as potential cardiac donors (main criteria: age < 60 years, no history of cardiac disease). AS diagnosis included increased systolic arterial pressure > 200 mm Hg associated with tachycardia >140 beats/min. Heart acceptance criteria were associated creatine kinase (CK), troponin Ic, and left ventricle ejection fraction (LVEF) estimated by echocardiography and visual inspection. RESULTS AS was observed in 29 patients (63%). Hypertension was treated in 12 patients (esmolol n = 6, urapidil n = 5, nicardipine). Cardiac harvesting was performed in 28 donors (61%). LVEFs were significantly higher after AS treatment (no AS: 55.4 +/- 13.4%, untreated AS: 49.0 +/- 18.8%, treated AS: 63.9+ +/- 10.3%, P = 0.049). AS treatment was found to be independently associated with LVEF in > 50% of the cases (P = 0.034). Treatment of AS or the lack of AS were associated with an increased probability of successful cardiac transplantation (OR = 8.8; 95% CI 2.1-38.3, P = 0.002). CONCLUSIONS Treatment of hypertension during AS may attenuate brain death-induced myocardial dysfunction and increase the number of available cardiac grafts.
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Affiliation(s)
- Gérard Audibert
- Service d'Anesthésie-Réanimation, Centre Hospitalier Universitaire de Nancy, Nancy, France
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Ferrera R, Bopassa J, Rodriguez C, Baverel G, Ovize M. High energy compound stability during experimental brain death. Transplant Proc 2006; 38:2285-6. [PMID: 16980066 DOI: 10.1016/j.transproceed.2006.06.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to examine the effect of sudden brain death (BD) on myocardial function and high energy phosphate (HEP) stores. BD was induced by cerebral vessel ligation in six swine (BD group) that were compared to six control swine. At the end of the BD period (3 hours), harvested hearts were stored at 4 degrees C. Myocardial tissue HEP were assessed by: (i) (31)P-NMR spectroscopy of left ventricle for phosphocreatine (PCr), adenosine triphosphate (ATP), inorganic phosphate (Pi) and intracellular pH (pHi), and by (ii) HPLC for ATP, ADP, and AMP levels in left ventricle biopsies. Brain death resulted in a instantaneous major increase in catecholamines (>50-fold, P < .001) and paradoxically a significant progressive decrease in the regional contractility of the left ventricle. After cardioplegia, no significant differences on HEP compounds (ATP/Pi, PCr/Pi, ATP, energetic index) or in pHi were observed between BD and control groups. These data suggest that early heart injury occurring during BD does not seem to be an ischemic phenomenon.
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Affiliation(s)
- R Ferrera
- INSERM EMI-U 0226, Laboratoire de Physiologie, Faculté de médecine Lyon-Nord, 8 avenue Rockefeller, 69373 Lyon Cedex 08, France.
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Christé G, Hadour G, Ovize M, Ferrera R. Brain Death Does Not Change Epicardial Action Potentials and Their Response to Ischemia–Reperfusion in Open-chest Pigs. J Heart Lung Transplant 2006; 25:847-53. [PMID: 16818129 DOI: 10.1016/j.healun.2006.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2005] [Revised: 01/31/2006] [Accepted: 03/27/2006] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND It is debated whether brain death (BD) causes transient functional ischemia. In this investigation we used monophasic action potential (AP) recording during BD as a sensitive means to assess: (i) whether ischemia was present; and (ii) the effect of BD on a subsequent ischemia-reperfusion challenge. METHODS In Period 1, BD was induced (BD group, 6 pigs) or not induced (sham maneuver, control [C] group, 6 pigs), and effects were followed for 3 hours. In Period 2, left anterior descending (LAD) coronary artery ligation ischemia was applied for 20 minutes to all hearts, followed by 60-minute reperfusion. RESULTS In Period 1, plasma norepinephrine was 3.1-, 6.3- and 5-fold greater in BD than in C at 1, 120 and 180 minutes, respectively, and systolic blood pressure was 26% greater at 1 minute and 35% at 120 minutes. The arteriovenous difference in lactate was similar or lower in BD than in C. In both groups, at all time-points, the action potential recording had a rectangular plateau shape and action potential duration (APD50) had a linear relationship to the cardiac inter-beat (RR) interval (R2 = 0.89 and 0.73, slope = 0.42 +/- 0.02 and 0.46 +/- 0.06 in BD and C, respectively). In Period 2, ischemia caused a similar (50%) APD shortening in BD and C. Restoration of the APD upon reperfusion was complete in both groups. CONCLUSIONS Our findings suggest that BD does not cause direct cardiac ischemia and does not change the response of the heart to subsequent ischemia-reperfusion challenge.
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Affiliation(s)
- Georges Christé
- INSERM EMI-0219, Laboratoire de Développement et Vieillissement de l'Endothélium, CEA Grenoble, Grenoble.
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Oishi Y, Nishimura Y, Tanoue Y, Kajihara N, Imasaka KI, Morita S, Yasui H. Endothelin-1 receptor antagonist prevents deterioration of left ventricular function and coronary flow reserve in brain-dead canine heart. J Heart Lung Transplant 2006; 24:1354-61. [PMID: 16143257 DOI: 10.1016/j.healun.2004.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2004] [Revised: 09/24/2004] [Accepted: 10/11/2004] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Rapid hemodynamic deterioration is caused by induction of brain death, but the exact mechanism is still uncertain. The aim of this study was to investigate the contribution of endothelin-1 by using endothelin-1 receptor antagonist (TAK-044) in a canine brain-death model. METHODS Dogs were divided into 2 groups: (1) the TAK group, in which TAK-044 was intravenously injected 30 minutes before brain-death induction at a dose of 3 mg/kg; and (2) the control group. Brain death was induced by rapid inflation of a sub-durally placed balloon catheter. Left ventricular function and coronary flow reserve was compared between the 2 groups. RESULTS Brain death caused a transient hyperdynamic response followed by hemodynamic deterioration after 60 minutes in both groups. Left ventricular function, evaluated by the slope of the end-systolic pressure-volume relation was significantly decreased from 7.7 +/- 0.6 to 3.7 +/- 0.3 mm Hg/ml (p < 0.01) in the control group, but was not decreased in the TAK group (7.7 +/- 0.8 to 7.3 +/- 0.9 mm Hg/ml, p = 0.75). Coronary flow reserve, measured by direct injection of acetylcholine (3 microg) into the coronary artery, was significantly reduced at 60 minutes after brain death in the control group (264.8% to 176.6%, p < 0.01), but not in the TAK group (291.2% to 301.3%, p = 0.84). Exactly the same results were obtained when sodium nitroprusside (SNP; 100 microg) was administered. CONCLUSIONS TAK-044 can prevent the deterioration of left ventricular function and coronary flow reserve that follows induction of brain death, suggesting that endothelin-1 could play an important role in hemodynamic deterioration by impairment of coronary microcirculation after brain death.
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Affiliation(s)
- Yasuhisa Oishi
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Abstract
Postresuscitation syndrome is a state of myocardial dysfunction after the restoration of circulation by successful resuscitation. Despite several advances in the field of resuscitation, the management of out-of-hospital cardiac arrest is still suboptimal. The high fatality rate shortly after successful resuscitation is mainly related to postresuscitation myocardial dysfunction. Postresuscitation myocardial stunning is reversible, while stony heart is irreversible due to prolonged unsuccessful resuscitation. This article reviews most of the published articles concerning the causes, mechanism, pathophysiology, and the updated trials for management of postresuscitation myocardial dysfunction. Further studies are warranted to highlight postresuscitation disease and its hemodynamic sequences and then to intervene according to the different phases of cardiac arrest. By modifying the conventional modalities of resuscitation together with new promising agents, the rescuers will be able to salvage the jeopardized postresuscitation myocardium and prevent its progression to the dismal stony heart. Community awareness and staff education are crucial to shorten resuscitation time and improve short-term and long-term outcomes. There is an urgent need to revise the guidelines for cardiopulmonary resuscitation in community setting, but how? It is a matter of where and when it is of enough value to be efficacious and cost-effective.
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Affiliation(s)
- Ayman A El-Menyar
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation and Hamad General Hospital, PO Box 3050, Doha, State of Qatar.
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Skrabal CA, Thompson LO, Potapov EV, Southard RE, Joyce DL, Youker KA, Noon GP, Loebe M. Organ-specific regulation of pro-inflammatory molecules in heart, lung, and kidney following brain death. J Surg Res 2005; 123:118-25. [PMID: 15652959 DOI: 10.1016/j.jss.2004.07.245] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND Nonspecific inflammatory events following brain death may increase the intensity of the immunological host response. The present study investigated the course of pro-inflammatory molecules in heart, lung, kidney, and plasma after brain death induction. MATERIALS AND METHODS Brain death was induced in five pigs by inflation of an intracranial Foley catheter and five pigs were sham-operated as controls. Each experiment was terminated 6 h after brain death/sham operation and the organs were harvested. We measured the mRNA and protein levels for TNF-alpha, IL-1beta, and IL-6 in heart, lung, kidney, and plasma. Additionally, the mRNA expression for IL-6R, ICAM-1, MCP-1, and TGF-beta was determined in each organ. RESULTS After 6 h, the plasma cytokine levels were higher in the brain-dead animals than in the sham-operated. In heart, lung, and kidney there was an increase in IL-6 and IL-1beta following brain death, while TNF-alpha was up-regulated in lung only (P < 0.05). MCP-1 and TGF-beta were significantly higher in heart and lung and IL-6R increased in heart after brain death (P < 0.05). CONCLUSIONS Brain death was associated with non-uniform cytokine expression patterns in the investigated organs. These expression patterns may cause variable pro-inflammatory priming resulting in different degrees of damage and explain the organ-specific variation in outcomes after transplantations.
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Affiliation(s)
- Christian A Skrabal
- Michael E. DeBakey Department of Surgery, Division of Transplant Surgery and Assist Devices, Baylor College of Medicine, Houston, Texas, USA.
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Karamlou T, Shen I, Slater M, Crispell K, Chan B, Ravichandran P. Decreased recipient survival following orthotopic heart transplantation with use of hearts from donors with projectile brain injury. J Heart Lung Transplant 2005; 24:29-33. [PMID: 15653375 DOI: 10.1016/j.healun.2003.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2003] [Revised: 09/30/2003] [Accepted: 10/08/2003] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Fatal gunshot injury to the brain can cause significant alterations in the neuroendocrine state and myocardial dysfunction. Therefore heart allografts from these donors may result in graft failure following orthotopic heart transplantation (OHTx). We evaluated whether receiving a heart from a donor who died from fatal gunshot wound to the brain independently affected the outcome of transplantation. METHODS A retrospective review of 113 consecutive patients undergoing OHTx at a university hospital from 1996 to 2002 was performed. Group 1 received hearts from donors with fatal gun shot brain injury (n = 17), and Group 2 received hearts from donors who died from other causes (n = 96). RESULTS Recipient age, gender, United Network for Organ Sharing (UNOS) status, indication for transplantation, and other co-morbid conditions were similar in both groups. Young male donors pre-dominated in Group 1, but other donor characteristics were not significantly different. The incidence of Grade 3A rejection was higher in Group 1 than Group 2 (35% vs 6.3%, p = 0.003), as was the incidence of post-operative infection (35% vs 7.2%, p = 0.004). Actuarial survival at 1 and 5 years was significantly lower in Group 1 than in Group 2 (81% and 74% vs 97% and 94%, respectively, p = 0.005). Multivariate logistic regression analysis also demonstrated that fatal gunshot brain injury, as cause of donor death, was a risk factor for recipient mortality (p = 0.01). CONCLUSION Receiving a heart from a donor with fatal gunshot brain injury is a significant risk factor for recipient mortality following OHTx. Cautious use of heart allograft from these donors, especially in low-risk recipients, may lead to improved outcome following heart transplantation.
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Affiliation(s)
- Tara Karamlou
- Department of Cardiothoracic Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Road, Portland, OR 97201, USA
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Herijgers P, Nishimura Y, Flameng W. Endothelial activation through brain death? J Heart Lung Transplant 2004; 23:S234-9. [PMID: 15381171 DOI: 10.1016/j.healun.2004.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2004] [Revised: 05/16/2004] [Accepted: 05/19/2004] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Brain death induces myocardial dysfunction and multifocal microscopic myocardial necrosis in dogs; however, the pathogenetic pathways between brain death and cardiac damage remain incompletely understood. We hypothesized that brain death might induce a propensity toward coronary vasospasms, possibly by endothelial dysfunction. We therefore studied the effect of serotonin and acetylcholine on tension generated by isolated coronary artery segments from control and brain dead dogs. METHODS Coronary segments were isolated 1 hour after brain death that was induced by the inflation (15 ml saline) of an extradurally placed balloon or from sham-operated time-matched controls. Studied were the effect of serotonin on isometric tension, with and without pre-constriction with prostaglandin F(2alpha) (PGF(2alpha)), and the effect of acetylcholine after pre-constriction. RESULTS Coronary segments from brain dead dogs exhibited severe vasoconstriction when serotonin (10(-7), 10(-6), and 10(-5) mol/liter) was administered, a reaction that was barely detectable in control segments. After pre-construction with PGF(2alpha), serotonin caused only significant vasodilation in a concentration of 10(-5) mol/liter, unlike in control segments where 10(-6) mol/liter had already induced a highly significant vasodilation. The reaction on acetylcholine was identical in both groups. CONCLUSION Brain death induces changes in coronary vasoreactivity in dogs, with a highly increased sensitivity for the vasospastic effects of serotonin. It is, however, not merely caused by aspecific endothelial dysfunction, as evidenced by the normal reaction on acetylcholine. These alterations in coronary artery properties might contribute to the myocardial damage seen after brain death.
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Affiliation(s)
- Paul Herijgers
- Cardiovascular Research Unit, Center for Experimental Surgery and Anaesthesiology, KU Leuven, Minderbroedersstraat 17, B-3000 Leuven, Belgium.
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McCrystal GD, Pepe S, Esmore DS, Rosenfeldt FL. The Challenge of Improving Donor Heart Preservation. Heart Lung Circ 2004; 13:74-83. [PMID: 16352173 DOI: 10.1016/j.hlc.2004.01.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Heart transplantation has in recent years become the treatment of choice for end stage heart failure. However while the waiting list for transplantation is growing steadily, the donor pool is not increasing. Therefore, in order to meet demand, transplant programs are using older, "marginal donors" and accepting longer ischaemic times for their donor hearts. As donor organs are injured as a consequence of brain death, during the period of donor management, at organ harvest, preservation, implantation and reperfusion, expansion of acceptance criteria places a great burden on achieving optimal long-term outcomes. However, at each step in the process of transplantation strategies can be employed to reduce the injury suffered by the donor organs. In this review, we set out what steps can be taken to improve the quality of donor organs.
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Affiliation(s)
- Graham D McCrystal
- Cardiac Surgical Research Unit, CJOB Department of Cardiothoracic Surgery, The Alfred Hospital and the Baker Heart Research Institute (Wynn Domain), Monash University, P.O. Box 6492, St. Kilda Rd. Central, Melbourne 8008, Vic., Australia
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22
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Boudaa C, Perrier JF, Lalot JM, Treuvey L, Voltz C, Strub P, Charpentier C, Audibert G, Meistelman C, Mertes PM, Longrois D. Analyse des critères qui participent à la décision de prélèvement cardiaque chez les patients en état de mort encéphalique. ACTA ACUST UNITED AC 2003; 22:765-72. [PMID: 14612163 DOI: 10.1016/j.annfar.2003.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The number of cardiac transplantation procedures does not increase because of the lack of donor hearts despite an increase in the number of brain-dead organ donors. The criteria used to select a donor heart are not formally standardized. The aim of the present study was to analyze the criteria that contribute to the selection of a donor heart. TYPE OF STUDY Descriptive, retrospective study. PATIENTS AND METHOD Clinical parameters, the initial causes that lead to brain death, maximum doses of catecholamines, several biochemical markers of myocardial ischaemia/necrosis as well as several echocardiography criteria were extracted from a prospectively collected database. Univariate and multivariate (logistic regression) analyses were performed with the "harvested heart" as dependent variable and the above-cited independent variables. RESULTS One hundred and eighty consecutive brain-dead patients admitted from 1st October 1998 to 31st December 2000 out of which 112 gave at least one organ were analyzed. Among these 112 patients, 59 (39 males and 20 females) were pre-selected as potential heart donors. Only 44 hearts were harvested. Logistic regression analysis showed that harvesting of the heart was more probable if the donor were a male, had no left ventricle systolic wall motion abnormalities, had low doses of norepinephrine and low serum troponin Ic concentrations. CONCLUSION After an initial phase of selection, the final decision to harvest a heart is based on several criteria. These results should be an incentive to conceive a score that could allow a more formal decision process for heart harvesting.
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Affiliation(s)
- C Boudaa
- Département d'anesthésie-réanimation chirurgicale, hôpital central, CO no 34, 54035 Nancy, France
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Ryan JB, Hicks M, Cropper JR, Garlick SR, Kesteven SH, Wilson MK, Feneley MP, Macdonald PS. Functional evidence of reversible ischemic injury immediately after the sympathetic storm associated with experimental brain death. J Heart Lung Transplant 2003; 22:922-8. [PMID: 12909474 DOI: 10.1016/s1053-2498(02)00558-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Acute brain death from increased intracranial pressure results in a transient increase in myocardial adenosine and lactate, which indicates that oxygen demand exceeds oxygen delivery during the sympathetic "storm". The aim of this study was to determine the functional significance of this period of ischemia. METHODS Brain death was inflicted on 40 Westran pigs (36.5-68.0 kg) by inflating a 21-ml subdural balloon over 3 minutes. In 38 animals, micromanometry and sonomicrometry were used to obtain left ventricular pressure-volume loops to determine the preload recruitable stroke work (PRSW) relationship. Data files were recorded before and at 15-minute intervals after beginning balloon inflation. Plasma troponin I was measured before and 60 minutes after beginning balloon inflation in the 38 instrumented and 2 non-instrumented animals. RESULTS All animals experienced the classical sympathetic storm. The slope of the PRSW relationship decreased, and the volume-axis intercept shifted to the right 15 minutes after beginning balloon inflation (p < 0.0001). Progressive incremental recovery (leftward shift) occurred between subsequent time points (p < or = 0.0018). In the instrumented animals, the mean plasma troponin I level increased from 1.4 +/- 1.6 microg/liter to 2.8 +/- 2.3 microg/liter (p < 0.001). However, troponin I was not detected before or after induction of brain death in the plasma of either non-instrumented animal (p = 0.001). CONCLUSIONS The sympathetic storm produced transient contractile dysfunction, consistent with ischemic injury. However, troponin I release reflected surgical instrumentation and not brain death.
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Affiliation(s)
- Jonathon B Ryan
- Heart and Lung Transplant Unit, St. Vincent's Hospital and the Victor Chang Cardiac Research Institute, Sydney, NSW, Australia.
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Mangino MJ, Kosieradzki M, Gilligan B, Woo H, Southard JH. The effects of donor brain death on renal function and arachidonic acid metabolism in a large animal model of hypothermic preservation injury. Transplantation 2003; 75:1640-7. [PMID: 12777849 DOI: 10.1097/01.tp.0000062541.10466.16] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Donor brain death (BD) has been implicated as a risk factor for the poor performance of kidneys after transplantation in small but not large animal models. This study determined the effects of donor BD on renal function and lipid mediator metabolism in a large animal model of renal hypothermic preservation injury. METHODS Adult beagle donors were subjected to explosive BD for 16 hr. After BD, the kidneys were removed, cold stored for 24 hr in cold University of Wisconsin solution, and allotransplanted into recipient dogs for either 4 hr (group 1) or 7 days (group 2). Controls for both groups consisted of kidneys obtained from living donors. Renal allograft function and tissue arachidonic acid (AA) metabolism were determined after reperfusion. RESULTS Short-term renal function after transplantation was generally unaffected by BD. Renal blood flow decreased after reperfusion but was not altered during the 16-hr BD period. Neutrophil infiltration significantly increased in kidneys from brain-dead donors before storage and after 4 hr of reperfusion. Renal cortex and medulla AA metabolism were not significantly affected by BD after short-term reperfusion except when thiol-ether leukotrienes (LTC(4)/D(4)/E(4)) were increased with BD. Serum creatinine was elevated during 7 days, but, surprisingly, BD significantly attenuated this injury. CONCLUSION BD in large mammals does not significantly affect renal allograft function or AA metabolism after transplantation. The role of BD in human renal preservation injury and inflammation should be reevaluated.
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Affiliation(s)
- Martin J Mangino
- Department of Surgery, University of Wisconsin School of Medicine, Madison 53792, USA.
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Lundgren A, Wilton J, Mölne J, Mobini R, Lukes DJ, Mårtensson C, Waagstein F, Olausson M. Impaired hepatic circulation despite normotension in brain-dead rats. Transplant Proc 2003; 35:773-4. [PMID: 12644131 DOI: 10.1016/s0041-1345(03)00038-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A Lundgren
- Department of Surgery and Transplantation, Sahlgrenska University Hospital, Göteborg, Sweden
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