John R. Spratt

Prolonged EVLP Using OCS Lung: Cellular and Acellular Perfusates.

Background We report the ability to extend lung preservation up to 24 hours (24H) by using autologous whole donor blood circulating within an ex vivo lung perfusion (EVLP) system. This approach facilitates donor lung reconditioning in a model of extended normothermic EVLP. We analyzed comparative responses to cellular and acellular perfusates to identify these benefits. Methods Twelve pairs of swine lungs were retrieved after cardiac arrest and studied for 24H on the Organ Care System (OCS) Lung EVLP platform. Three groups (n = 4 each) were differentiated by perfusate: (1) isolated red blood cells (RBCs) (current clinical standard for OCS); (2) whole blood (WB); and (3) acellular buffered dextran-albumin solution (analogous to STEEN solution). Results Only the RBC and WB groups met clinical standards for transplantation at 8 hours; our primary analysis at 24H focused on perfusion with WB versus RBC. The WB perfusate was superior (vs RBC) for maintaining stability of all monitored parameters, including the following mean 24H measures: pulmonary artery pressure (6.8 vs 9.0 mm Hg), reservoir volume replacement (85 vs 1607 mL), and PaO2:FiO2 ratio (541 vs 223). Acellular perfusion was limited to 6 hours on the OCS system due to prohibitively high vascular resistance, edema, and worsening compliance. Conclusions The use of an autologous whole donor blood perfusate allowed 24H of preservation without functional deterioration and was superior to both RBC and buffered dextran-albumin solution for extended lung preservation in a swine model using OCS Lung. This finding represents a potentially significant advance in donor lung preservation and reconditioning.

The ABCs of autologous blood collection for ex vivo organ preservation

Abstract Ex vivo organ perfusion (EVOP) using autologous whole donor blood (AWDB) allows prolonged preservation and extracorporeal assessment of solid organs for transplant. We present a straightforward methodology for ADWB collection that may be incorporated into standard clinical procurement.

An Experimental Study of the Recovery of Injured Porcine Lungs with Prolonged Normothermic Cellular Ex Vivo Lung Perfusion Following Donation after Circulatory Death

Donation after circulatory death (DCD) is an underused source of donor lungs. Normothermic cellular ex vivo lung perfusion (EVLP) is effective in preserving standard donor lungs but may also be useful in the preservation and assessment of DCD lungs. Using a model of DCD and prolonged EVLP, the effects of donor warm ischemia and postmortem ventilation on graft recovery were evaluated. Adult male swine underwent general anesthesia and heparinization. In the control group (n = 4), cardioplegic arrest was induced and the lungs were procured immediately. In the four treatment groups, a period of agonal hypoxia was followed by either 1 h of warm ischemia with (n = 4) or without (n = 4) ventilation or 2 h of warm ischemia with (n = 4) or without (n = 4) ventilation. All lungs were studied on an EVLP platform for 24 h. Hemodynamic measures, compliance, and oxygenation on EVLP were worse in all DCD lungs compared with controls. Hemodynamics and compliance normalized in all lungs after 24 h of EVLP, but DCD lungs demonstrated impaired oxygenation. Normothermic cellular EVLP is effective in preserving and monitoring of DCD lungs. Early donor postmortem ventilation and timely procurement lead to improved graft function.

Process Improvement in Thoracic Donor Organ Procurement: Implementation of a Donor Assessment Checklist

BACKGROUND Donor organs are often procured by junior staff in stressful, unfamiliar environments where a single adverse event can be catastrophic. A formalized checklist focused on preprocedural processes related to thoracic donor organ procurement could improve detection and prevention of near miss events. METHODS A checklist was developed centered on patient identifiers, organ compatibility and quality, and team readiness. It went through five cycles of feedback and revision using a panel of expert procurement surgeons. Educational in-service sessions were held on the use of the checklist as well as best organ assessment practices. Near miss events before the survey were tallied by retrospective review of 20 procurements, and near misses after checklist implementation were prospectively recorded. We implemented the checklist for 40 donor lung and heart procurements: 20 from Cleveland Clinic and 20 from the University of Minnesota. A final survey assessment was used to determine ease of use. RESULTS Nine near miss events were reported in 20 procurements before use of the checklist. Thirty-one near miss events of 40 organ procurements were identified and potentially prevented by the checklist. Eighty-seven percent of fellows found the checklist to be unobtrusive to work flow, and 100% believed its use should be mandatory. Mortality was the same before and after implementation of the checklist despite increased patient volumes. CONCLUSIONS Implementation of a simple checklist for use during thoracic organ procurement uncovered a substantial number of near miss events. A preprocedural checklist for all thoracic organ transplants in the United States and abroad is feasible and would likely reduce adverse events.

Novel percutaneous mechanical circulatory support devices and their expanding applications

ABSTRACT Introduction: Temporary mechanical circulatory support (MCS) is a common supportive therapy in cardiogenic shock and high-risk coronary intervention. The proliferation of new percutaneous MCS devices allows support to be instituted rapidly without surgical cutdown. The recent literature exploring the indications, benefits, and risks of each is reviewed. Areas discussed: Current applications of percutaneous MCS devices, including intra-aortic balloon pumps (IAPB), Impella, TandemHeart, and VA ECMO are discussed. Studies investigating each were identified through a combination of online database queries and direct extraction of single studies cited in previously-identified papers. Information on unpublished trials and registries was found on ClinicalTrials.gov. Expert commentary: Direct VADs provide a higher level of hemodynamic support compared to IABP and their early use will continue to expand. The development of percutaneous RV support systems may allow more patients to receive such therapy faster. VA ECMO is being used increasingly in CPR and in outreach programs.

Endobronchial valve therapy for a refractory air leak after lung transplantation in a patient with multiple connective tissue disorders.

From the Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication June 14, 2016; revisions received Sept 23, 2016; accepted for publication Sept 30, 2016; available ahead of print Nov 1, 2016. Address for reprints: Sara J. Shumway, MD, Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, 420 Delaware St SE, Mayo Mail Code 195, Minneapolis, MN 55455 (E-mail: shumw001@umn.edu). J Thorac Cardiovasc Surg 2017;153:e17-8 0022-5223/

Lung transplant after prolonged ex vivo lung perfusion: predictors of allograft function in swine

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.09.069 EBV after deployment in the RML.

Historical perspectives of The American Association for Thoracic Surgery: Pedro J. del Nido

Portable normothermic EVLP has been evaluated in clinical trials using standard and extended‐criteria donor lungs. We describe a swine model of lung transplant following donation after circulatory death using prolonged normothermic EVLP to assess the relationship between EVLP data and acute lung allograft function. Adult swine were anesthetized and heparinized. In the control group (n = 4), lungs were procured, flushed, and transplanted. Treatment swine underwent either standard procurement (n = 3) or agonal hypoxia followed by 1 (n = 4) or 2 hours (H) (n = 4) of ventilated warm ischemia. Lungs were preserved for 24H using normothermic blood‐based EVLP then transplanted. Recipients were monitored for 4 H. After 24H of preservation, mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), and dynamic compliance (Cdyn) were improved in all EVLP groups. After transplant, EVLP groups showed similar allograft oxygenation. EVLP PVR, mPAP, and lung block weights had significant negative correlations with post‐transplant allograft oxygenation. EVLP P:F ratio did not correlate with acute post‐transplant allograft function until 24H of preservation. Data measured in the first 8H of EVLP were sufficient for predicting acute post‐transplant allograft function. This study provides a benchmark and platform for evaluation of therapies for donor‐related allograft injury in injured lungs treated with prolonged normothermic EVLP.

Adult Orthotopic Heart Transplantation: Early Complications

From the Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn; and Division of Pediatric Cardiothoracic Surgery, University of Texas SouthwesternMedical Center and Children’s Medical Center, Dallas, Tex. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Oct 11, 2016; accepted for publication Oct 15, 2016. Address for reprints: Sara J. Shumway, MD, Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, 420 Delaware St, SE, Mayo Mail Code 195, Minneapolis, MN 55455 (E-mail: shumw001@umn.edu). J Thorac Cardiovasc Surg 2016;-:1-3 0022-5223/

Management of left ventricular pseudoaneurysm: A single-institution case series

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.10.011