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Anderson DJ, Jones-Carr M, Perry J, Kumar V, Porrett PM, Locke JE. Genetically Modified Porcine Kidneys Have Sufficient Tissue Integrity for Use in Pig-to-Human Xenotransplantation. Ann Surg 2024; 280:374-382. [PMID: 38842179 DOI: 10.1097/sla.0000000000006380] [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: 06/07/2024]
Abstract
OBJECTIVE We sought to determine if genetically modified porcine kidneys used for xenotransplantation had sufficient tissue integrity to support long-term function in a human recipient. BACKGROUND Kidney transplantation remains the best available treatment for patients with end-stage kidney disease. However, a shortage of available donor human kidneys prevents many patients from achieving the benefits of transplantation. Xenotransplantation is a potential solution to this shortage. Recent pre-clinical human studies have demonstrated kidneys from genetically modified pig donors can be transplanted without hyperacute rejection and are capable of providing creatinine and other solute clearance. It is unknown whether the porcine kidneys would tolerate the relatively higher resting blood pressure in an adult human recipient compared with the pig donor or non-human primate (NHP) recipients used in translational studies. Furthermore, previous experience in NHPs raised concerns about the tissue integrity of the porcine ureter and post-xenotransplant growth of the porcine kidney. METHODS Kidneys recovered from porcine donors with 10 gene edits were transplanted into decedent brain-dead recipients who were not eligible for organ donation. Decedents underwent bilateral native nephrectomy before transplant and were followed for 3 to 7 days. Standard induction and maintenance immunosuppression was used as previously reported. Vital signs, including blood pressure, were recorded frequently. Kidney xenografts were assessed daily, serially biopsied, and were measured at implantation and study completion. RESULTS Three decedents underwent successful xenotransplantation. Subcapsular hematomas developed, requiring incision of the xenograft capsules to prevent Page kidney. Blood pressures were maintained in a physiologic range for adult humans (median arterial pressures (MAP) 108.5 mm Hg (Interquartile Range (IQR): 97-114 mm Hg), 74 mm Hg (IQR: 71-78 mm Hg), and 95 mm Hg (IQR: 88-99 mm Hg, respectively) and no bleeding complications or aneurysm formation was observed. Serial biopsies were taken from the xenografts without apparent loss of tissue integrity despite the lack of a capsule. Ureteroneocystotomies remained intact without evidence of urine leak. Xenograft growth was observed, but plateaued, in 1 decedent with increased volume of the left and right xenografts by 25% and 26%, respectively, and in the context of human growth hormone levels consistently less <0.1 ng/ml and insulin-like growth factor 1 levels ranging from 34-50 ng/ml. CONCLUSIONS The findings of this study suggest kidneys from 10-gene edited porcine donors have sufficient tissue integrity to tolerate xenotransplantation into a living human recipient. There was no evidence of anastomotic complications, and the xenografts tolerated needle biopsy without issue. Xenograft growth occurred but plateaued by the study end; further observation and investigation will be required to confirm this finding and elucidate underlying mechanisms.
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Affiliation(s)
- Douglas J Anderson
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
- Department of Surgery, Division of Transplantation, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Maggie Jones-Carr
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
- Department of Surgery, Division of Transplantation, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Jackson Perry
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
- Department of Surgery, Division of Transplantation, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Vineeta Kumar
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
- Department of Medicine, Division of Nephrology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Paige M Porrett
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
- Department of Surgery, Division of Transplantation, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
- Department of Surgery, Division of Transplantation, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
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Cruz-López EO, Merkus D, Danser AHJ. Blood Pressure Monitoring Through Radiotelemetry: Exploring the Viability of Its Application in Multihoused Small Laboratory Animals. Hypertension 2024; 81:947-950. [PMID: 38630797 DOI: 10.1161/hypertensionaha.124.22756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Affiliation(s)
- Edwyn O Cruz-López
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (E.O.C.-L., A.H.J.D.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Daphne Merkus
- Department of Cardiology, Cardiovascular Institute, Thorax Center (D.M.), Erasmus University Medical Center, Rotterdam, the Netherlands
- Walter Brendel Center for Experimental Medicine, University Clinic Munich, Ludwig-Maximilians-Universität Munich, Germany (D.M.)
- Center for Cardiovascular Research, Munich Heart Alliance, Partner Site Munich, Germany (D.M.)
| | - A H Jan Danser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (E.O.C.-L., A.H.J.D.), Erasmus University Medical Center, Rotterdam, the Netherlands
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Bender M, Panelli A, Reichart B, Radan J, Mokelke M, Neumann E, Buttgereit I, Michel S, Bauer A, Fresch AK, Mayr T, Werner F, Egerer S, Bähr A, Kessler B, Klymiuk N, Ayares D, Wolf E, Hagl C, Brenner P, Längin M, Abicht J. Hemodynamics in pig-to-baboon heterotopic thoracic cardiac xenotransplantation: Recovery from perioperative cardiac xenograft dysfunction and impairment by cardiac overgrowth. Xenotransplantation 2024; 31:e12841. [PMID: 38864375 PMCID: PMC11167678 DOI: 10.1111/xen.12841] [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: 04/04/2023] [Revised: 09/04/2023] [Accepted: 12/19/2023] [Indexed: 06/13/2024]
Abstract
INTRODUCTION Orthotopic cardiac xenotransplantation has seen notable improvement, leading to the first compassionate use in 2022. However, it remains challenging to define the clinical application of cardiac xenotransplantation, including the back-up strategy in case of xenograft failure. In this regard, the heterotopic thoracic technique could be an alternative to the orthotopic procedure. We present hemodynamic data of heterotopic thoracic pig-to-baboon transplantation experiments, focusing on perioperative xenograft dysfunction and xenograft overgrowth. METHODS We used 17 genetically modified piglets as donors for heterotopic thoracic xenogeneic cardiac transplantation into captive-bred baboons. In all animals, pressure probes were implanted in the graft's left ventricle and the recipient's ascending aorta and hemodynamic data (graft pressure, aortic pressure and recipient's heart rate) were recorded continuously. RESULTS Aortic pressures and heart rates of the recipients' hearts were postoperatively stable in all experiments. After reperfusion, three grafts presented with low left ventricular pressure indicating perioperative cardiac dysfunction (PCXD). These animals recovered from PCXD within 48 h under support of the recipient's heart and there was no difference in survival compared to the other 14 ones. After 48 h, graft pressure increased up to 200 mmHg in all 17 animals with two different time-patterns. This led to a progressive gradient between graft and aortic pressure. With increasing gradient, the grafts stopped contributing to cardiac output. Grafts showed a marked weight increase from implantation to explantation. CONCLUSION The heterotopic thoracic cardiac xenotransplantation technique is a possible method to overcome PCXD in early clinical trials and an experimental tool to get a better understanding of PCXD. The peculiar hemodynamic situation of increasing graft pressure but missing graft's output indicates outflow tract obstruction due to cardiac overgrowth. The heterotopic thoracic technique should be successful when using current strategies of immunosuppression, organ preservation and donor pigs with smaller body and organ size.
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Affiliation(s)
- Martin Bender
- Department of AnaesthesiologyUniversity Hospital, LMU MunichMunichGermany
| | - Alessandro Panelli
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM)Charité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Bruno Reichart
- Transregional Collaborative Research Center 127Walter Brendel Centre of Experimental MedicineLMU MunichMunichGermany
| | - Julia Radan
- Transregional Collaborative Research Center 127Walter Brendel Centre of Experimental MedicineLMU MunichMunichGermany
| | - Maren Mokelke
- Transregional Collaborative Research Center 127Walter Brendel Centre of Experimental MedicineLMU MunichMunichGermany
| | - Elisabeth Neumann
- Transregional Collaborative Research Center 127Walter Brendel Centre of Experimental MedicineLMU MunichMunichGermany
| | - Ines Buttgereit
- Department of AnaesthesiologyUniversity Hospital, LMU MunichMunichGermany
| | - Sebastian Michel
- Department of Cardiac SurgeryUniversity HospitalLMU MunichMunichGermany
| | - Andreas Bauer
- Department of AnaesthesiologyUniversity Hospital, LMU MunichMunichGermany
| | - Ann Kathrin Fresch
- Transregional Collaborative Research Center 127Walter Brendel Centre of Experimental MedicineLMU MunichMunichGermany
| | - Tanja Mayr
- Department of AnaesthesiologyUniversity Hospital, LMU MunichMunichGermany
| | - Fabian Werner
- Transregional Collaborative Research Center 127Walter Brendel Centre of Experimental MedicineLMU MunichMunichGermany
| | - Stefanie Egerer
- Gene Center and Department of Veterinary SciencesInstitute of Molecular Animal Breeding and BiotechnologyLMU MunichMunichGermany
| | - Andrea Bähr
- Gene Center and Department of Veterinary SciencesInstitute of Molecular Animal Breeding and BiotechnologyLMU MunichMunichGermany
| | - Barbara Kessler
- Gene Center and Department of Veterinary SciencesInstitute of Molecular Animal Breeding and BiotechnologyLMU MunichMunichGermany
| | - Nikolai Klymiuk
- Gene Center and Department of Veterinary SciencesInstitute of Molecular Animal Breeding and BiotechnologyLMU MunichMunichGermany
| | | | - Eckhard Wolf
- Gene Center and Department of Veterinary SciencesInstitute of Molecular Animal Breeding and BiotechnologyLMU MunichMunichGermany
- Center for Innovative Medical Models (CiMM)LMU MunichMunichGermany
- Interfaculty Center for Endocrine and Cardiovascular Disease Network Modelling and Clinical Transfer (ICONLMU)LMU MunichMunichGermany
| | - Christian Hagl
- Department of Cardiac SurgeryUniversity HospitalLMU MunichMunichGermany
| | - Paolo Brenner
- Department of Cardiac SurgeryUniversity HospitalLMU MunichMunichGermany
| | - Matthias Längin
- Department of AnaesthesiologyUniversity Hospital, LMU MunichMunichGermany
| | - Jan‐Michael Abicht
- Department of AnaesthesiologyUniversity Hospital, LMU MunichMunichGermany
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Stand der Technik und Durchbruch bei der kardialen Xenotransplantation. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2022. [DOI: 10.1007/s00398-022-00534-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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DiChiacchio L, Singh AK, Lewis B, Zhang T, Hardy N, Pasrija C, Morales D, Odonkor P, Strauss E, Williams B, Deatrick KB, Kaczorowski DJ, Ayares D, Griffith BP, Bartlett ST, Mohiuddin MM. Early Experience With Preclinical Perioperative Cardiac Xenograft Dysfunction in a Single Program. Ann Thorac Surg 2019; 109:1357-1361. [PMID: 31589847 DOI: 10.1016/j.athoracsur.2019.08.090] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/16/2019] [Accepted: 08/28/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Perioperative cardiac xenograft dysfunction (PCXD) was described by McGregor and colleagues as a major barrier to the translation of heterotopic cardiac xenotransplantation into the orthotopic position. It is characterized by graft dysfunction in the absence of rejection within 24 to 48 hours of transplantation. We describe our experience with PCXD at a single program. METHODS Orthotopic transplantation of genetically engineered pig hearts was performed in 6 healthy baboons. The immunosuppression regimen included induction by anti-CD20 monoclonal antibodies (mAb), thymoglobulin, cobra venom factor, and anti-CD40 mAb, and maintenance with anti-CD40 mAb, mycophenolate mofetil, and tapering doses of steroids. Telemetry was used to assess graft function. Extracorporeal membrane oxygenation was used to support 1 recipient. A full human clinical transplantation team was involved in these experiments and the procedure was performed by skilled transplantation surgeons. RESULTS A maximal survival of 40 hours was achieved in these experiments. The surgical procedures were uneventful, and all hearts were weaned from cardiopulmonary bypass without issue. Support with inotropes and vasopressors was generally required after separation from cardiopulmonary bypass. The cardiac xenografts performed well immediately, but within the first several hours they required increasing support and ultimately resulted in arrest despite maximal interventions. All hearts were explanted immediately; histology showed no signs of rejection. CONCLUSIONS Despite excellent surgical technique, uneventful weaning from cardiopulmonary bypass, and adequate initial function, orthotopic cardiac xenografts slowly fail within 24 to 48 hours without evidence of rejection. Modification of preservation techniques and minimizing donor organ ischemic time may be able to ameliorate PCXD.
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Affiliation(s)
- Laura DiChiacchio
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Avneesh K Singh
- Department of Surgery, University of Maryland Baltimore, School of Medicine, Baltimore, Maryland
| | - Billeta Lewis
- Department of Surgery, University of Maryland Baltimore, School of Medicine, Baltimore, Maryland
| | - Tianshu Zhang
- Department of Surgery, University of Maryland Baltimore, School of Medicine, Baltimore, Maryland
| | - Naomi Hardy
- Department of Pathology, University of Maryland Medical Center, Baltimore, Maryland
| | - Chetan Pasrija
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - David Morales
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Patrick Odonkor
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Erik Strauss
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Brittney Williams
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | | | - David J Kaczorowski
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | | | - Bartley P Griffith
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Stephen T Bartlett
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Muhammad M Mohiuddin
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland.
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Hörer J. Current spectrum, challenges and new developments in the surgical care of adults with congenital heart disease. Cardiovasc Diagn Ther 2018; 8:754-764. [PMID: 30740322 DOI: 10.21037/cdt.2018.10.06] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Today, more than two thirds of patients with congenital heart disease (CHD) are adults. Cardiac surgery plays an essential role in restoring and maintaining cardiac function, aside from evolving medical treatment and catheter-based interventions. The aim of the present publication was to describe the spectrum of operations performed on adults with CHD (ACHD) by reviewing current literature. Currently, surgery for ACHD is predominantly valve surgery, since valvular pathologies are often either a part of the basic heart defect or develop as sequelae of corrective or palliative surgery. Surgical techniques for valve repair, established in patients with acquired heart disease (non-ACHD), can often be transferred to ACHD. New valve substitutes may help to reduce the number of redo operations. Most of valve operations yield good results in terms of survival and quality of life, with the precondition that the ventricular function is preserved. Heart failure due to end-stage CHD is the most frequent cause of mortality in ACHD. However, surgical treatment by means of mechanical circulatory support (MCS) is still uncommon and the mortality exceeds the one following other operations in ACHD. Currently, different devices are used and new technical developments are in progress. However, there still is no ideal assist device available. Therefore, heart transplantation remains the only valid option for end-stage CHD. Despite higher early mortality following heart transplantation in ACHD compared to non-ACHD, the long-term survival compares favorably to non-ACHD. There is room for improvement by refining the indications, the time of listing, and the perioperative care of ACHD transplant patients. Sudden death is the second most frequent cause of mortality in ACHD. Ventricular tachycardia is the most frequent cause of sudden death followed by coronary artery anomaly. Due to the increasing awareness of physicians and the improved imaging techniques, coronary artery anomalies are coming more into the focus of cardiac surgeons. However, the reported experience is limited and it is currently difficult to provide a standardized and generally applicable recommendation for the indication and the adequate surgical technique. With the increasing age and complexity of ACHD, treatment of rhythm disturbances by surgical ablation, pacemaker or implantable cardioverter defibrillator (ICD) implantation and resynchronisation gains importance. A risk score specifically designed for surgery in ACHD is among the newest developments in predicting the outcome of surgical treatment of ACHD. This evidence-based score, derived from and validated with data from the Society of Thoracic Surgeons Congenital Heart Surgery Database, enables comparison of risk-adjusted performance of the whole spectrum of procedures performed in ACHD and helps in understanding the differences in surgical outcomes. The score is thus a powerful tool for quality control and quality improvement. In conclusion, new developments in surgery for ACHD are currently made with regard to valve surgery, which comprises more than half of all operations in ACHD and in treatment of end-stage CHD, which still yields high mortality and morbidity.
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Affiliation(s)
- Jürgen Hörer
- Department of Pediatric Cardiology and Congenital Heart Disease, Hôpital Marie Lannelongue, Université Paris-Sud, Le Plessis Robinson, France
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