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Lung Lavage and Surfactant Administration for the Ex Vivo Pre-Transplant Treatment of Donor Lungs Injured Due to Gastric Acid Aspiration
S92
The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015
Methods: Yorkshire male pigs (27-37 kg) were used. Donor lungs were harvested and preserved for 24 h at 4°C followed by left single lung transplantation. Animals in the control arm (n= 5) received human albumin, and in the treatment arm (n= 5) received human A1AT (240 mg/kg), before reperfusion intravenously in a randomized blinded fashion. Allograft function was assessed by means of hourly pulmonary vein gas sampling until 4 h of reperfusion followed by occlusion of the right pulmonary artery to assess the oxygenation function of the isolated allograft. Static compliance of the respiratory system was determined by obtaining pressure-volume curves during low-flow (5 L/min) insufflation of tidal volume from 5 cmH2O of positive end expiratory pressure, at 30 minutes and 4 h after reperfusion. Results: Pulmonary gas exchange was significantly better during the 4 h observation period and after occlusion of the right pulmonary artery in the treatment arm (Fig 1A). Pulmonary edema, evaluated by wet/dry weight ratio, was significantly lower in the treated lungs (Control: 9.2 +/- 0.6 vs. A1AT: 6.9 +/− 0.3; p < 0.05). Treatment with A1AT induced a notable improvement in the static respiratory system compliance, especially at the end of the experimental period (Fig 1B). Conclusion: Pretreatment with A1AT improved immediate post-transplant lung function. Further studies elucidating mechanisms of the beneficial effect of A1AT in this setting, and evaluation of this therapy in a large animal survival model are needed. This study was partially supported by the Canadian Institutes of Health Research and the CSL Behring.
lung compliance was significantly higher in SL group at 4 hours after Tx, compared with other groups (SL: 15.5±2.2 mL/cmH2O; control: 9.3±2.1 mL/ cmH2O; LL: 8.4±2.0 mL/cmH2O; SF: 10.6±3.6 mL/cmH2O; P = 0.0023). Conclusion: Lung lavage followed by trans-bronchial administration of exogenous surfactant during EVLP provides superior post-transplant lung function using donor lungs injured with gastric acid aspiration.
2( 33) Ex-Vivo Therapeutic Use of Carbon Monoxide (CO) to Improve Donor Lungs for Transplantation R. Kalaf-Mussi , J. Lee, D. Nakajima, M. Chen, L. Maahs, R. Coutinho, M. Liu, S. Keshavjee, M. Cypel. Latner Thoracic Surgery Research Laboratories, Toronto Lung Transplant Program, University Health Ne, University of Toronto, Toronto, ON, Canada.
2( 32) Lung Lavage and Surfactant Administration for the Ex Vivo Pre-Transplant Treatment of Donor Lungs Injured Due to Gastric Acid Aspiration D. Nakajima , A. Ohsumi, I. Iskender, R. Kalaf, M. Chen, R. Coutinho, T. Kanou, L. Maahs, P. Behrens, J. Sakamoto, J. Lee, P. Mordant, M. Hsin, S. Azad, T.K. Waddell, T. Martinu, M. Cypel, M. Liu, S. Keshavjee. Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, Toronto, ON, Canada. Purpose: The presence of gastric acid aspiration is a common reason to decline donor lungs for transplantation (Tx). We hypothesized that lung lavage could remove alveolar debris, reduce inflammatory activity, and provide uniformly distributed exogenous surfactant replacement to aid in lung recovery and improve lung function. Methods: After lung injury was induced by 100 mL of gastric juice (pH= 3.0), pigs were ventilated for 6 hours and then the lungs were retrieved. Following 10 hours of cold ischemic time, ex vivo lung perfusion (EVLP) was performed for 6 hours. The lungs were randomly divided into 4 groups (n= 5, each): 1) no treatment (control); 2) lung lavage (LL); 3) surfactant administration (SF); 4) surfactant administration following lung lavage (SL). Lung lavage was performed using 200 mL of saline after 1 hour of EVLP. Shortly after, natural, bovine lipid extracted surfactant (36 mg phospholipid/kg) was administered into each segment via bronchoscope. Following 2 hours of second cold ischemic time, the left lung was transplanted and reperfused for 4 hours in all the groups. Results: Donor lung function similarly deteriorated after aspiration injury in all animals. EVLP function (pulmonary compliance, oxygenation, and vascular resistance) significantly improved in SL group, compared with control and LL groups (P < 0.05). Importantly, after Tx, PaO2/FiO2 remained significantly higher in SL group, compared to other groups (Figure 1). Similarly,
Purpose: Ex-vivo lung perfusion (EVLP) is a method that provides an ideal platform to assess the effects of therapeutics on ischemia-reperfusion injury. We set to study the potential for ex vivo treatment of injured donor lungs by using exogenous Carbon Monoxide (CO) during normothermic EVLP followed by transplantation (LTx). Methods: Porcine donor lungs after conventional retrieval were subjected to a prolonged cold ischemic time of 18h followed by 6 h of EVLP. Lungs were then randomly allocated to EVLP alone (control group, n= 5) or delivery of 500 ppm of CO for 1h by ventilation after 20 min of EVLP initiation (CO group, n= 5). After EVLP, lungs were cooled again to 4ºC for 2h and the left lungs were transplanted. Four hours after LTx, lung function was assessed. Samples from lung tissue, plasma, and perfusate were collected in both groups for biochemical analysis. Results: At the end of EVLP, pulmonary vascular resistance (494 ± 69.72 dynes.s.cm-5 vs. 285.4 ± 19.72; p= 0.0066) and Wet/Dry ratio (6.112 ± 0.3631 vs. 5.112 ± 0.2634; p= 0.0294) were reduced in CO group. After LTx, and clamping of the contra-lateral pulmonary artery and bronchus, systemic PaO2/FiO2 was significantly better in CO group (312.44 ± 92.97 mmHg vs. 453.60 ± 53.60 mmHg p= 0.0317). Furthermore, a higher lung static compliance (12.44 ± 3.73 mLcm H2O-1 vs. 17.24 ± 2.67 mLcm H2O-1; p= 0.0159) and a lower peek airway pressure (18.40 ± 1.14 cmH2O vs. 15.80 ± 1.48 cmH2O; p= 0.0345) and Wet/Dry ratio (6.626 ± 0.745 vs 5.305 ± 0.4519; p= 0.0037). Samples collected from perfusate and tissue during EVLP demonstrated a decrease in myeloperoxidase (MPO) (p= 0.0281), endotelin-1 (p= 0.0079) and M30 (p= 0.0079), and an elevation of IL-10 (p= 0.0278) in CO group. After LTx, there was a decrease in inflammatory response represented by a lower IL-6 (p= 0.0465), MPO (p= 0.0079), endotelin-1 (p= 0.0317) and a higher IL-10 (p= 0.0278) in CO group. Cell death assessment using M30 demonstrated a significantly lower rate in CO group (p= 0.0476). Conclusion: Delivery of CO by ventilation to the lung has a significant beneficial impact during EVLP, which reflects in significant better function, less inflammation and less cell death after transplantation in a porcine preclinical model.
The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015
Methods: Yorkshire male pigs (27-37 kg) were used. Donor lungs were harvested and preserved for 24 h at 4°C followed by left single lung transplantation. Animals in the control arm (n= 5) received human albumin, and in the treatment arm (n= 5) received human A1AT (240 mg/kg), before reperfusion intravenously in a randomized blinded fashion. Allograft function was assessed by means of hourly pulmonary vein gas sampling until 4 h of reperfusion followed by occlusion of the right pulmonary artery to assess the oxygenation function of the isolated allograft. Static compliance of the respiratory system was determined by obtaining pressure-volume curves during low-flow (5 L/min) insufflation of tidal volume from 5 cmH2O of positive end expiratory pressure, at 30 minutes and 4 h after reperfusion. Results: Pulmonary gas exchange was significantly better during the 4 h observation period and after occlusion of the right pulmonary artery in the treatment arm (Fig 1A). Pulmonary edema, evaluated by wet/dry weight ratio, was significantly lower in the treated lungs (Control: 9.2 +/- 0.6 vs. A1AT: 6.9 +/− 0.3; p < 0.05). Treatment with A1AT induced a notable improvement in the static respiratory system compliance, especially at the end of the experimental period (Fig 1B). Conclusion: Pretreatment with A1AT improved immediate post-transplant lung function. Further studies elucidating mechanisms of the beneficial effect of A1AT in this setting, and evaluation of this therapy in a large animal survival model are needed. This study was partially supported by the Canadian Institutes of Health Research and the CSL Behring.
lung compliance was significantly higher in SL group at 4 hours after Tx, compared with other groups (SL: 15.5±2.2 mL/cmH2O; control: 9.3±2.1 mL/ cmH2O; LL: 8.4±2.0 mL/cmH2O; SF: 10.6±3.6 mL/cmH2O; P = 0.0023). Conclusion: Lung lavage followed by trans-bronchial administration of exogenous surfactant during EVLP provides superior post-transplant lung function using donor lungs injured with gastric acid aspiration.
2( 33) Ex-Vivo Therapeutic Use of Carbon Monoxide (CO) to Improve Donor Lungs for Transplantation R. Kalaf-Mussi , J. Lee, D. Nakajima, M. Chen, L. Maahs, R. Coutinho, M. Liu, S. Keshavjee, M. Cypel. Latner Thoracic Surgery Research Laboratories, Toronto Lung Transplant Program, University Health Ne, University of Toronto, Toronto, ON, Canada.
2( 32) Lung Lavage and Surfactant Administration for the Ex Vivo Pre-Transplant Treatment of Donor Lungs Injured Due to Gastric Acid Aspiration D. Nakajima , A. Ohsumi, I. Iskender, R. Kalaf, M. Chen, R. Coutinho, T. Kanou, L. Maahs, P. Behrens, J. Sakamoto, J. Lee, P. Mordant, M. Hsin, S. Azad, T.K. Waddell, T. Martinu, M. Cypel, M. Liu, S. Keshavjee. Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, Toronto, ON, Canada. Purpose: The presence of gastric acid aspiration is a common reason to decline donor lungs for transplantation (Tx). We hypothesized that lung lavage could remove alveolar debris, reduce inflammatory activity, and provide uniformly distributed exogenous surfactant replacement to aid in lung recovery and improve lung function. Methods: After lung injury was induced by 100 mL of gastric juice (pH= 3.0), pigs were ventilated for 6 hours and then the lungs were retrieved. Following 10 hours of cold ischemic time, ex vivo lung perfusion (EVLP) was performed for 6 hours. The lungs were randomly divided into 4 groups (n= 5, each): 1) no treatment (control); 2) lung lavage (LL); 3) surfactant administration (SF); 4) surfactant administration following lung lavage (SL). Lung lavage was performed using 200 mL of saline after 1 hour of EVLP. Shortly after, natural, bovine lipid extracted surfactant (36 mg phospholipid/kg) was administered into each segment via bronchoscope. Following 2 hours of second cold ischemic time, the left lung was transplanted and reperfused for 4 hours in all the groups. Results: Donor lung function similarly deteriorated after aspiration injury in all animals. EVLP function (pulmonary compliance, oxygenation, and vascular resistance) significantly improved in SL group, compared with control and LL groups (P < 0.05). Importantly, after Tx, PaO2/FiO2 remained significantly higher in SL group, compared to other groups (Figure 1). Similarly,
Purpose: Ex-vivo lung perfusion (EVLP) is a method that provides an ideal platform to assess the effects of therapeutics on ischemia-reperfusion injury. We set to study the potential for ex vivo treatment of injured donor lungs by using exogenous Carbon Monoxide (CO) during normothermic EVLP followed by transplantation (LTx). Methods: Porcine donor lungs after conventional retrieval were subjected to a prolonged cold ischemic time of 18h followed by 6 h of EVLP. Lungs were then randomly allocated to EVLP alone (control group, n= 5) or delivery of 500 ppm of CO for 1h by ventilation after 20 min of EVLP initiation (CO group, n= 5). After EVLP, lungs were cooled again to 4ºC for 2h and the left lungs were transplanted. Four hours after LTx, lung function was assessed. Samples from lung tissue, plasma, and perfusate were collected in both groups for biochemical analysis. Results: At the end of EVLP, pulmonary vascular resistance (494 ± 69.72 dynes.s.cm-5 vs. 285.4 ± 19.72; p= 0.0066) and Wet/Dry ratio (6.112 ± 0.3631 vs. 5.112 ± 0.2634; p= 0.0294) were reduced in CO group. After LTx, and clamping of the contra-lateral pulmonary artery and bronchus, systemic PaO2/FiO2 was significantly better in CO group (312.44 ± 92.97 mmHg vs. 453.60 ± 53.60 mmHg p= 0.0317). Furthermore, a higher lung static compliance (12.44 ± 3.73 mLcm H2O-1 vs. 17.24 ± 2.67 mLcm H2O-1; p= 0.0159) and a lower peek airway pressure (18.40 ± 1.14 cmH2O vs. 15.80 ± 1.48 cmH2O; p= 0.0345) and Wet/Dry ratio (6.626 ± 0.745 vs 5.305 ± 0.4519; p= 0.0037). Samples collected from perfusate and tissue during EVLP demonstrated a decrease in myeloperoxidase (MPO) (p= 0.0281), endotelin-1 (p= 0.0079) and M30 (p= 0.0079), and an elevation of IL-10 (p= 0.0278) in CO group. After LTx, there was a decrease in inflammatory response represented by a lower IL-6 (p= 0.0465), MPO (p= 0.0079), endotelin-1 (p= 0.0317) and a higher IL-10 (p= 0.0278) in CO group. Cell death assessment using M30 demonstrated a significantly lower rate in CO group (p= 0.0476). Conclusion: Delivery of CO by ventilation to the lung has a significant beneficial impact during EVLP, which reflects in significant better function, less inflammation and less cell death after transplantation in a porcine preclinical model.