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386: Ex-Vivo Reconditioning of Marginal Donor Lungs Injured by Acid Aspiration
S200
Abstracts
T.K. Waddell,1 M. de Perrot,1 S. Keshavjee,1 1Thoracic Surgery Department, Toronto Lung Transplant Program, Latner Thoracic Surgery Laboratory, University of Toronto, Toronto, ON, Canada Purpose: We have demonstrated the feasibility of prolonged (12h) EVLP without adding further injury to the lungs. The objective of this study was to examine the impact of EVLP on ischemic injury and cellular metabolism during the period of preservation. Methods and Materials: Pig donor lungs were preserved in Perfadex® for 12h at 40C and subsequently divided into two groups(n⫽4/ group):Cold static preservation(CSP) or EVLP with Steen® solution for a further 12h. The left lung was transplanted at the end of preservation and reperfused for 4h. Lung function was assessed by measuring PaO2 and edema formation using wet to dry ratio.Lung histology and T lymphocyte infiltration was evaluated. Cell cytoskeleton integrity was studied during the period of preservation and after transplantation using the tight junction protein ZO-1 immunofluorescent staining of frozen lung tissue.The presence of active cell metabolism during EVLP was confirmed using ex-vivo trans-tracheal GFP gene transfer studies. Results: EVLP preservation provided significantly better lung oxygenation (PaO2: 473.70 vs 126.61mmHg*) and lower edema formation rates (W/D:5.90.5 vs 8.20.5*) after transplantation. This was accompanied by improved histologic appearance and decreased T-lymphocyte infiltration in the EVLP group (26.0 vs 57.7 CD3⫹ cells per field)*p⬍0.05. ZO-1 was dispersed in the cell membranes of the CSP group, however, in the EVLP group, ZO-1 staining pattern was comparable to normal lungs-intense subjunctional cytoplasmic plaque-type staining. Integrity of functional metabolic pathways was demonstrated by effective gene transfer and GFP protein production by epithelial cells and macrophages. Conclusions: EVLP interrupts ongoing injury caused by prolonged cold ischemia. The maintenance of barrier functional integrity during EVLP translates into a significant attenuation of reperfusion injury and better performance of the graft after transplantation. By ameliorating the injury process and maintaining active cell metabolism, EVLP could be used as a platform to repair damaged donor lungs. 386 Ex-Vivo Reconditioning of Marginal Donor Lungs Injured by Acid Aspiration I. Inci,1 L. Ampollini,1 S. Arni,1 W. Jungraithmayr,1 P. Vogt,2 B. Leskosek,1 S. Hillinger,1 W. Weder,1 1Department of Thoracic Surgery, University of Zurich, Zurich, Switzerland; 2Department of Pathology, University of Zurich, Zurich, Switzerland Purpose: Injured lungs due to gastric acid aspiration may be rejected for transplantation because of the possibility of early graft dysfunction. Several experiments have demonstrated that the pulmonary surfactant system is harmed in acute lung injury. We hypothesized diluted surfactant administration during ex vivo perfusion would recondition the lungs injured by acid aspiration and permit their use as suitable grafts for transplantation. Methods and Materials: Lung injury was induced by 5 ml/kg with betaine-HCl/pepsin mixture (pH: 1.5) via flexible bronchoscope. After injury pigs were randomly assigned into 3 study groups (n⫽6); saline lavage during exvivo perfusion (Control); surfactant lavage exvivo (SL-Exvivo); surfactant lavage before harvest (SL-Pre). Normal group (n⫽4); no lung injury. Cold storage time was 3 hours. A volume of 10 ml/kg (4 mg/ml, 40 mg/kg) surfactant (Curosurf®) was used for lavage. Bronchoalveolar lavage (BAL) was performed before and after injury and at the end of the experiment. Surfactant function, phospholipids, protein and neutrophil percentage in BAL were assessed. Hemodynamic and aerodynamic parameters were measured every 30 min during 2 hours of observation period. At the end of observation
The Journal of Heart and Lung Transplantation February 2008
period wet to dry weight ratio was calculated and histological examination was performed. Results: Approximately 50% decrease in PaO2 was observed in all animals after injury. Ex vivo surfactant lavage resulted in lower pulmonary vascular resistance, lower oxygenation index and higher PaO2/FiO2 ratio compared to control group (p⫽0.001, p ⫽0.0001, and p⫽0.0001, respectively. Analysis of variance for repeated measures). Wet to dry weight ratio was lower in SLExvivo compared to control group (p⫽0.015). BAL neutrophil percentage at the end of the experiment significantly differed between control versus all groups (p⬍0.05). Conclusions: Diluted surfactant lavage during ex-vivo perfusion improves the graft function of lungs injured by gastric aspiration.
387 Ex-Vivo Assessment of Donor Hearts with the OCS To Detect Hidden Pathologies S. Tsui,1 K. Dhital,1 C. Eisenring,2 A. Ardehali,2 1Cardiothoracic Surgery, Papworth Hospital, Papworth, United Kingdom; 2 Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA Purpose: The Organ Care System (OCS) maintains explanted donor hearts in near-physiologic functioning state. This allows further ex-vivo evaluation of metabolic and functional parameters, right up to the time of cardiac implantation. We report our experience of using the OCS for ex-vivo assessment of donor hearts and describe its utility in identifying serious hidden pathologies that were undetectable at time of retrieval. Methods and Materials: 14 donor hearts were examined according to standard protocol and were deemed acceptable for transplantation at time of retrieval, based on hemodynamics, echocardiography assessment and the absence of palpable coronary artery disease. All donor hearts were instrumented on OCS. Perfusion parameters (PP) including coronary flow (CF), aortic pressure (AOP) and heart rate, were continuously displayed on OCS. Serial arterial and coronary sinus blood samples were taken for lactate levels (LACT). Donor hearts displaying abnormal parameters on the OCS were not transplanted. Histopathological examination (HPE) was conducted as a confirmatory tool on the unused hearts. Results: Twelve of the 14 accepted donor hearts displayed satisfactory PP and LACT on the OCS and were successfully transplanted. All 12 transplanted recipients survived to hospital discharge. Two donor hearts displayed significant rise in serial LACT despite adequate CF (1.95 mg/dl to 5.15 mg/dl and 4.38 to 10.7 mg/dl, respectively). Case 1: 45 Y male, cause of death: cerebral bleed; Case 2: 24 Y male, cause of death: motorcycle accident. Case 1 also displayed significantly elevated AOP (67.7 ⫹/- 12.7mmHg). Based on abnormal parameters, these 2 donor hearts were not transplanted. HPE revealed widespread and severe coronary artery disease with ⬎95% stenosis in case 1, and myocardial contusion of the LV and RV walls in case 2. Conclusions: OCS PP & LACT are important parameters in the ex-vivo assessment of donor hearts. The OCS has shown to unmask hidden donor heart pathologies and has the potential to reduce recipient morbidity and mortality.
388 Predicting the Metabolic State of Donor Hearts Prior to Implantation in a Large Animal Model of Perfusion Preservation
Abstracts
T.K. Waddell,1 M. de Perrot,1 S. Keshavjee,1 1Thoracic Surgery Department, Toronto Lung Transplant Program, Latner Thoracic Surgery Laboratory, University of Toronto, Toronto, ON, Canada Purpose: We have demonstrated the feasibility of prolonged (12h) EVLP without adding further injury to the lungs. The objective of this study was to examine the impact of EVLP on ischemic injury and cellular metabolism during the period of preservation. Methods and Materials: Pig donor lungs were preserved in Perfadex® for 12h at 40C and subsequently divided into two groups(n⫽4/ group):Cold static preservation(CSP) or EVLP with Steen® solution for a further 12h. The left lung was transplanted at the end of preservation and reperfused for 4h. Lung function was assessed by measuring PaO2 and edema formation using wet to dry ratio.Lung histology and T lymphocyte infiltration was evaluated. Cell cytoskeleton integrity was studied during the period of preservation and after transplantation using the tight junction protein ZO-1 immunofluorescent staining of frozen lung tissue.The presence of active cell metabolism during EVLP was confirmed using ex-vivo trans-tracheal GFP gene transfer studies. Results: EVLP preservation provided significantly better lung oxygenation (PaO2: 473.70 vs 126.61mmHg*) and lower edema formation rates (W/D:5.90.5 vs 8.20.5*) after transplantation. This was accompanied by improved histologic appearance and decreased T-lymphocyte infiltration in the EVLP group (26.0 vs 57.7 CD3⫹ cells per field)*p⬍0.05. ZO-1 was dispersed in the cell membranes of the CSP group, however, in the EVLP group, ZO-1 staining pattern was comparable to normal lungs-intense subjunctional cytoplasmic plaque-type staining. Integrity of functional metabolic pathways was demonstrated by effective gene transfer and GFP protein production by epithelial cells and macrophages. Conclusions: EVLP interrupts ongoing injury caused by prolonged cold ischemia. The maintenance of barrier functional integrity during EVLP translates into a significant attenuation of reperfusion injury and better performance of the graft after transplantation. By ameliorating the injury process and maintaining active cell metabolism, EVLP could be used as a platform to repair damaged donor lungs. 386 Ex-Vivo Reconditioning of Marginal Donor Lungs Injured by Acid Aspiration I. Inci,1 L. Ampollini,1 S. Arni,1 W. Jungraithmayr,1 P. Vogt,2 B. Leskosek,1 S. Hillinger,1 W. Weder,1 1Department of Thoracic Surgery, University of Zurich, Zurich, Switzerland; 2Department of Pathology, University of Zurich, Zurich, Switzerland Purpose: Injured lungs due to gastric acid aspiration may be rejected for transplantation because of the possibility of early graft dysfunction. Several experiments have demonstrated that the pulmonary surfactant system is harmed in acute lung injury. We hypothesized diluted surfactant administration during ex vivo perfusion would recondition the lungs injured by acid aspiration and permit their use as suitable grafts for transplantation. Methods and Materials: Lung injury was induced by 5 ml/kg with betaine-HCl/pepsin mixture (pH: 1.5) via flexible bronchoscope. After injury pigs were randomly assigned into 3 study groups (n⫽6); saline lavage during exvivo perfusion (Control); surfactant lavage exvivo (SL-Exvivo); surfactant lavage before harvest (SL-Pre). Normal group (n⫽4); no lung injury. Cold storage time was 3 hours. A volume of 10 ml/kg (4 mg/ml, 40 mg/kg) surfactant (Curosurf®) was used for lavage. Bronchoalveolar lavage (BAL) was performed before and after injury and at the end of the experiment. Surfactant function, phospholipids, protein and neutrophil percentage in BAL were assessed. Hemodynamic and aerodynamic parameters were measured every 30 min during 2 hours of observation period. At the end of observation
The Journal of Heart and Lung Transplantation February 2008
period wet to dry weight ratio was calculated and histological examination was performed. Results: Approximately 50% decrease in PaO2 was observed in all animals after injury. Ex vivo surfactant lavage resulted in lower pulmonary vascular resistance, lower oxygenation index and higher PaO2/FiO2 ratio compared to control group (p⫽0.001, p ⫽0.0001, and p⫽0.0001, respectively. Analysis of variance for repeated measures). Wet to dry weight ratio was lower in SLExvivo compared to control group (p⫽0.015). BAL neutrophil percentage at the end of the experiment significantly differed between control versus all groups (p⬍0.05). Conclusions: Diluted surfactant lavage during ex-vivo perfusion improves the graft function of lungs injured by gastric aspiration.
387 Ex-Vivo Assessment of Donor Hearts with the OCS To Detect Hidden Pathologies S. Tsui,1 K. Dhital,1 C. Eisenring,2 A. Ardehali,2 1Cardiothoracic Surgery, Papworth Hospital, Papworth, United Kingdom; 2 Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA Purpose: The Organ Care System (OCS) maintains explanted donor hearts in near-physiologic functioning state. This allows further ex-vivo evaluation of metabolic and functional parameters, right up to the time of cardiac implantation. We report our experience of using the OCS for ex-vivo assessment of donor hearts and describe its utility in identifying serious hidden pathologies that were undetectable at time of retrieval. Methods and Materials: 14 donor hearts were examined according to standard protocol and were deemed acceptable for transplantation at time of retrieval, based on hemodynamics, echocardiography assessment and the absence of palpable coronary artery disease. All donor hearts were instrumented on OCS. Perfusion parameters (PP) including coronary flow (CF), aortic pressure (AOP) and heart rate, were continuously displayed on OCS. Serial arterial and coronary sinus blood samples were taken for lactate levels (LACT). Donor hearts displaying abnormal parameters on the OCS were not transplanted. Histopathological examination (HPE) was conducted as a confirmatory tool on the unused hearts. Results: Twelve of the 14 accepted donor hearts displayed satisfactory PP and LACT on the OCS and were successfully transplanted. All 12 transplanted recipients survived to hospital discharge. Two donor hearts displayed significant rise in serial LACT despite adequate CF (1.95 mg/dl to 5.15 mg/dl and 4.38 to 10.7 mg/dl, respectively). Case 1: 45 Y male, cause of death: cerebral bleed; Case 2: 24 Y male, cause of death: motorcycle accident. Case 1 also displayed significantly elevated AOP (67.7 ⫹/- 12.7mmHg). Based on abnormal parameters, these 2 donor hearts were not transplanted. HPE revealed widespread and severe coronary artery disease with ⬎95% stenosis in case 1, and myocardial contusion of the LV and RV walls in case 2. Conclusions: OCS PP & LACT are important parameters in the ex-vivo assessment of donor hearts. The OCS has shown to unmask hidden donor heart pathologies and has the potential to reduce recipient morbidity and mortality.
388 Predicting the Metabolic State of Donor Hearts Prior to Implantation in a Large Animal Model of Perfusion Preservation