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Ann Thorac Surg 2000;69:1556-1562
© 2000 The Society of Thoracic Surgeons

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Original articles: General thoracic

Pulmonary graft function after long-term preservation of non-heart-beating donor lungs

^a Department of Surgery, University of Munich, Munich, Germany
^b Institute of Pathology, University of Munich, Munich, Germany
^c Institute for Surgical Research, University of Munich, Munich, Germany

Address reprint requests to Dr Loehe, Department of Surgery, University of Munich, Marchioninistr 15, D-81377 Munich, Germany;
e-mail: floehe{at}gch.med.uni-muenchen.de

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Critical organ shortage in lung transplantation could be attenuated by the use of non-heart-beating donor (NHBD) lungs. In addition, prolonged ischemic tolerance of the organs would contribute to the alleviation of organ shortage. The aim of this study was to investigate pulmonary graft function of NHBD lungs after long-term hypothermic storage.

Methods. Twelve native-bred pigs (bodyweight 20 to 30 kg) underwent left lung allotransplantation. In the heart-beating donor (HBD) group, lungs were harvested immediately after cardiac arrest. In the NHBD group, lungs were subjected to a warm ischemic period of 90 minutes before harvesting. After a total ischemic time of 19 hours, pulmonary grafts in both groups were reperfused and pulmonary graft function was assessed. All values were compared with a sham-operated control group.

Results. Pulmonary graft function in the HBD group was excellent. In the NHBD group, pulmonary gas exchange was impaired, but still provided good graft function compared with the excellent graft function in the HBD group. Pulmonary vascular resistance was even lower in the NHBD group. In the NHBD group, calculated intrapulmonary shunt fraction (Q_s/Q_t) was significantly increased compared with the sham-group. Histologic alteration and wet-to-dry ratio did not differ significantly between the HBD and NHBD group.

Conclusions. We conclude that NHBD lungs (90 minutes of warm ischemic time) have the potential to alleviate organ shortage in lung transplantation even after an extended total ischemic time.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Despite the success in therapy of end-stage lung disease, the number of lung transplantations has not further increased and has maintained at a plateau since 1993 [1]. This fact is due to a critical organ shortage, although there is an increasing number of patients on the waiting lists. Besides a limited number, only 10% to 20% of organ donors have suitable lungs for transplantation [2].

The urge to increase the donor pool and allograft availability has revived the interest in procuring organs from asystolic donors, so-called non-heart-beating donors (NHBD). In contrast to brain dead heart-beating donors (HBD) with maintained organ perfusion, organs of NHBD are retrieved after cessation of circulation [3–5]. Recent clinical experience could demonstrate that the acceptance of NHBD has raised renal transplantation rates up to 20% to 40% [4, 6]. The possibility of continued oxygen extraction from the alveoli after cessation of perfusion, allowing ongoing cellular aerobic metabolism, makes the lung an ideal candidate for non-heart-beating donation [7]. In experimental models, lungs of NHBD demonstrated good pulmonary graft function after a warm ischemic period of 30 minutes [8] and up to 2 hours [3]. In these studies, the warm ischemic period was, however, followed by a only short-term hypothermic storage of 1.5 and 4 hours after recovering the organs. In the clinical situation, a prolongation of allograft ischemic time seems to be necessary for alleviation of organ shortage, because it allows prospective HLA matching and retrieval of organs from donors far away [9, 10].

The objective of the present study was the investigation of pulmonary graft function of NHBD lungs after long-term hypothermic storage compared with the graft function of lungs procured from HBD in a porcine model.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
All experiments were approved by the responsible government (AZ 211-2531-59/97) and carried out in accordance with the "Guide for the Care and Use of Laboratory Animals" of the National Institutes of Health (publication No. 85-23, revised 1985).

For premedication, all animals were sedated intramuscularly with atropine (0.05 mg/kg), azeperone (12 mg/kg), and ketamine (15 mg/kg) followed by inducing anesthesia with intravenous piritramide (0.5 mg/kg) and sodium-thiopental (6 mg/kg). All animals were paralyzed with pancuronium (0.2 mg/kg), and tracheotomy was performed. After endotracheal intubation, the animals were ventilated with intermittent positive pressure ventilation (Servo 900; Siemens, Solna, Sweden) at a respiratory volume/minute of 240 mL/kg and with a respiratory rate of 12/minute. Positive end-expiratory pressure (PEEP) of 5 cm H₂O and an inspired oxygen fraction (FiO₂) of 1.0 were adjusted. Single lung ventilation was performed using a double-lumen tracheal tube after disconnecting the contralateral lung from ventilation and retaining the respiratory volume by increasing the respiratory rate to 22/minute.

The lateral neck was dissected and an arterial and central venous catheter were inserted in the external carotid artery and the subclavian vein. Anesthesia was maintained by continuous administration of piritramide (1 mg/kg/h), pancuronium (0.4 mg/kg/h), and sodium-thiopental (3 mg/kg/h) intravenously.

Donor procedure
Twelve native bred pigs (20 to 30 kg body weight) served as organ donors. After a median sternotomy, the pericardium was incised and the thymus removed. The pulmonary trunk was cannulated with a 24F catheter and secured with a tourniquet. All animals received 10,000 IU heparin intravenously.

Animals in the heart beating group (HBD, n = 6) slowly received 200 µg epoprostenol intravenously. The superior and inferior caval veins were ligated, the aorta clamped, and cardiac arrest induced by injecting 20 mL 1 mol/L potassium-chloride into the aortic root proximal to the clamp. Immediately after cardiac arrest, the left atrial appendage was incised and lungs of the HBD group were flushed with 60 mL/kg cold (4°C) low-potassium-dextran solution (LPD, Perfadex; XVIVO Transplantation Systems, Göteborg, Sweden) (Table 1). Flush perfusion was carried out from a height of 50 cm along the force of gravity. Ventilation was continued throughout flushing.

Heart-lung blocks were dissected and the heart was excised. The inflated lungs were placed in cold Ringer’s solution and stored at 4°C for 17 hours.

Recipient procedure
On the following day, weight-matched recipient animals were anesthesized and endobronchially intubated with a 35F double-lumen left broncho-catheter (Mallinckrodt Co., London, England). Furthermore, a Swan-Ganz catheter was placed in the pulmonary artery and was connected to a REF-1 CO-Computer (Baxter, Santa Ana, CA). Urinary output was measured by a cystostomy, which was carried out via a mini-laparotomy.

Left lung transplantation was performed through a left thoracotomy. The lung was mobilized by dividing the pulmonary ligament and hemiazygous vein close to the left arterial appendage. Lymphatic tissue was dissected and left pulmonary artery and main bronchus were isolated. The dorsal pericardium was incised and a tourniquet was placed around the right pulmonary artery. Care was taken to place the tourniquet proximal to the first branch of the right pulmonary artery. Left pulmonary veins were ligated and sectioned. The left pulmonary artery and left main stem bronchus were clamped, and the left lung was excised. After pneumonectomy, 10,000 IU heparin was given intravenously and implantation commenced with the bronchial anastomoses, followed by the pulmonary arterial and left atrial anastomosis. All anastomoses were performed using a continuous monofilament suture (5/0 Prolene). Before completion of the arterial suture, the pulmonary artery and the left atrium were flushed to remove air. After manual inflation to reopen atelectasis, the allograft was ventilated and reperfusion started. The thoracotomy was closed with towel clamps. Two hours after the beginning of reperfusion, 5,000 IU heparin was administered intravenously.

After an observation period of 5 hours, all animals were sacrificed painlessly in anesthesia by administering 20 mL of a 1 mol/L potassium-chloride solution intravenously. Total ischemic time consisted of the warm ischemic period (time between cardiac arrest and pulmonary artery flush), hypothermic storage time (time between pulmonary flushing and beginning of implantation), and time needed for implantation.

To assess the operative trauma caused by dissecting the lung hilum, 6 animals (sham group) received the complete recipient procedure with isolating the hilar structures, but without carrying out pneumonectomy and transplantation.

Lung function
After insertion of all catheters and before sternotomy or thoracotomy, baseline parameters of pulmonary gas exchange (paO₂, paCO₂, pH) and systemic hemodynamics (mean arterial pressure [MAP], heart rate [HR], cardiac output [CO]) and pulmonary hemodynamics (mean pulmonary arterial pressure [MPAP], pulmonary capillary wedge pressure [PCWP]) were measured during double-lung ventilation and perfusion. Dynamic lung compliance (C_dyn mL/cm H₂O) was calculated as tidal volume/peak airway pressure.

Pulmonary graft function was assessed during 10 minutes of isolated ventilation and perfusion 1, 2, 4, and 5 hours after starting reperfusion by measuring pulmonary gas exchange and hemodynamics afterwards. Isolated perfusion and ventilation of the pulmonary graft was achieved by occluding the right pulmonary artery using a tourniquet and disconnecting the right lung from ventilation. In a similar manner, native lung function was assessed 3 and 5 hours after starting the reperfusion by clamping the left pulmonary artery and disconnecting the pulmonary graft from ventilation.

Because measurement of the PCWP using the Swan-Ganz catheter is not possible in single-lung perfusion, the PCWP during double-lung perfusion was used for calculating the pulmonary vascular resistance:

in single-lung perfusion.

Central venous blood samples were taken at the beginning of the operation and 2, 3, and 5 hours after reperfusion for measuring pvO₂ and pvCO₂. The arterial (CaO₂) and central venous oxygen content (CvO₂) was calculated with the formula:

The intrapulmonary shunt (Qs/Qt) was computed using a formula dealing with values for paO₂ greater than 150 mm Hg:

At the beginning of the donor and recipient operation and hourly during the observation period, measurements of hemoglobin (g/dL), white blood count (G/L), and platelet count (G/L) were obtained.

W/D ratio and histologic examination
To evaluate the wet-to-dry weight (W/D) ratio, two tissue specimens of the upper and lower lobe of the pulmonary graft and the right native lung were taken and weighed immediately after finishing the observation period. After drying for 72 hours at 100°C, samples were weighed again and the W/D ratio was calculated.

At the same time, lung biopsies were taken from the upper and lower lobe for histologic examination. Specimens were fixed in 4% buffered formalin and were embedded in paraffin. Sections of 4 µm were stained with eosin and hematoxylin. Before histologic examination by a pathologist (I.B.), stained sections were blinded with a numeric code. A semiquantitive score was calculated based on the evaluation of endothelial alteration, alveolar-cell desquamation, leukocyte adhesion, intraalveolar edema, and fibrin exudation. The morphologic changes were graded as described before by Müller and colleagues [11] as: 0 = normal, 1 = mild, 2 = moderate, and 3 = severe changes.

Statistical analysis
All values are given as mean and standard error of the mean (SEM). Analysis of variance (ANOVA) and normality test were carried out. Parameters of the different groups were compared using a one-way repeated measures ANOVA on ranks test and a Student-Newman-Keuls test when there was a difference between the groups; p less than 0.05 was considered significant.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
There were no significant differences in pulmonary gas exchange, hemodynamics, dynamic lung compliance, blood cell counts, and body weight of donor and recipient animals. Total ischemic period including the time needed for implantation did not differ between the HBD group (19 ± 0.1 hours) and the NHBD group (18.8 ± 0.08 hours).

One hour after pulmonary graft reperfusion, MAP measured during double-lung ventilation and perfusion was reduced to 62.5 ± 2.3 mm Hg as compared with baseline values in the NHBD group. In contrast to this, MAP in the HBD group (68.5 ± 4.8 mm Hg) and sham group (79.3 ± 5.7 mm Hg) was not different from the baseline values. However, the differences between the groups were not significant.

All animals tolerated clamping of the pulmonary artery and disconnecting one lung from ventilation for measurements during isolated ventilation and perfusion of the pulmonary graft or the right native lung.

After starting graft reperfusion, hemodynamic parameters during isolated graft perfusion and ventilation did not show significant differences between the study groups, although there was a tendency towards lower values for MAP and increased CO in the NHBD group (Table 2). There was a tendency towards the highest values for MPAP in the HBD group and the lowest in sham group.

View larger version (16K): [in this window] [in a new window]   Fig 1. Pulmonary vascular resistance (PVR) during isolated perfusion and ventilation of the pulmonary graft. Data are shown as mean ± SEM. *p < 0.05, HBD group vs NHBD and sham groups.

PaO₂ in the HBD and NHBD groups was only in the first hour after reperfusion lower than in the sham group during isolated graft perfusion and ventilation (p < 0.05). PaO₂ in the NHBD group was significantly lower than in the HBD group (p < 0.05) since the second hour after reperfusion (Fig 2).

View larger version (16K): [in this window] [in a new window]   Fig 2. Arterial oxygen tension (paO2) during isolated perfusion and ventilation of the pulmonary graft. Data are shown as mean ± SEM. *p < 0.05, sham group vs NHBD group; +p < 0.05, sham group vs HBD group; #p < 0.05 HBD group vs NHBD group.

Mean paCO₂ values in the NHBD group during isolated ventilation and perfusion of the pulmonary graft were elevated compared with the HBD and sham groups. This difference was significant (p < 0.05) between the NHBD and sham groups since the second hour after graft reperfusion (Fig 3).

View larger version (16K): [in this window] [in a new window]   Fig 3. Arterial carbon dioxide tension (paCO2) during isolated perfusion and ventilation of the pulmonary graft. Data are shown as mean ± SEM. *p < 0.05 NHBD group vs sham group.

W/D ratio of tissue specimens (Fig 4) from pulmonary grafts did not differ between the HBD (8.8 ± 0.3), NHBD (8.8 ± 0.2), and sham groups (8.5 ± 0.2), but were significantly (p < 0.05) increased compared with the W/D ratio of the right native lungs (HBD group: 7.2 ± 0.2, NHBD group: 7.5 ± 0.4, sham group: 6.6 ± 0.3).

View larger version (19K): [in this window] [in a new window]   Fig 4. W/D ratio of tissue specimens. Data are shown as mean ± SEM.

	Comment

Top Abstract Introduction Material and methods Results Comment References

In 1991, Egan and coworkers [3] observed an adequate pulmonary graft function of NHBD lungs after 2 hours of warm ischemic time before cold flush perfusion. However, after 4 hours of warm ischemic time, pulmonary graft function was significantly impaired. Recently, Greco and colleagues [16] were able to demonstrate that there was no difference in pulmonary gas exchange and hemodynamics when comparing lungs from NHBD lungs (warm ischemic time of 90 minutes) and from HBD without warm ischemia before harvesting. Furthermore, lungs of NHBD with a warm ischemic time of 30 minutes performed equally well 1 week after transplantation in a survival model as those of HBD [8].

After harvesting the NHBD lungs, the cold ischemic periods in the cited studies were relatively short, with a maximum of 4 hours. The question of whether NHBD lungs will tolerate a long-term storage, as successfully performed in experimental HBD studies, remains unanswered. Our study is the first one investigating the effect of 90 minutes of warm ischemic time before long-term hypothermic storage on pulmonary graft function.

As in most published experimental NHBD studies, the donor animals were heparinized before inducing cardiac arrest to avoid thrombosis in the pulmonary artery and its branches as a cause for poor graft function. According to the accepted standard in the clinical setting, the intravenous application of epoprostenol before flushing the lungs was performed to prevent pulmonary vasoconstriction due to organ flushing [10, 17]. Therefore, donor animals in the HBD group of our study also received 200 µg epoprostenol previous to induced cardiac arrest. In contrast to this, no epoprostenol was administered before organ procurement in the NHBD group. This protocol mimics the clinical situation of non-heart-beating organ donation, in which the application of vasoactive substances before the cessation of circulation is not possible.

The maximum acceptable ischemic storage period in clinical lung transplantation is considered to be 6 to 8 hours [18]. The magnitude of deterioration of pulmonary gas exchange and pulmonary vascular resistance correlates with the length of the ischemic time period [9]. Numerous experimental trials have dealt with the improvement of flush solutions for organ preservation in order to increase ischemic tolerance [19]. Worldwide, the most frequently used flush solution in clinical lung procurement is currently Euro-Collins [10, 18]. Egan and coworkers [3] and Buchanan and coworkers [8] also used Euro-Collins for organ flushing in their experimental studies of pulmonary graft function of NHBD lungs. However, several animal studies indicate an improvement of pulmonary graft function of HBD and a successful extension of ischemic time up to 24 hours when LPD solutions are used [20, 21].

In our study, pulmonary graft function after long-term preservation and transplantation in the HBD group was excellent. Pulmonary gas exchange of the pulmonary grafts in the HBD group revealed only a small difference compared with the sham group. A significant impairment of pulmonary gas exchange was observed in the NHBD group, but pulmonary grafts in this group were still providing good function after long-term preservation. Greco and colleagues [16] noticed no difference in pulmonary graft function of lungs procured from NHBD with 90 minutes of warm ischemia when compared with pulmonary grafts from HBD. Nevertheless, in this study, cold ischemic time reached a maximum of only 1.5 hours and was comparably short.

In an experimental trial, Egan and coworkers [3] demonstrated the possibility of extending the warm ischemic time of NHBD lungs up to 2 hours, but 3 out of 5 recipient animals died after transplantation during the observation period of 8 hours, caused by poor pulmonary graft function. Furthermore, variability in the gas exchange of the pulmonary graft of our NHBD group indicates that an extension of the warm ischemic period for more than 90 minutes would not be reasonable.

According to other studies [11, 16, 22], vascular resistance of the pulmonary graft increased continuously after reperfusion in the HBD group. In contrast to this, our investigations showed no increase in PVR in the NHBD group, and calculated values were significantly lower compared with the HBD group. Because histologic examination did not reveal significant differences between the groups, the lower PVR in the NHBD group might be due to an increased pulmonary shunt fraction in this group.

There was no significant difference concerning the histologic examination and W/D ratio of the pulmonary grafts after 5 hours of reperfusion between our study groups, with a tendency towards a greater degree of morphologic alterations in the NHBD group and less changes in the sham group compared with the right native lungs. Morphologic changes and the increase of the W/D ratio in the sham group are based on the effect of denuding the lung hilum, which results in vascular dysfunction and development of mild alveolar edema [23].

Based on our results, we conclude good pulmonary graft function after long-term hypothermic storage of NHBD lungs with a warm ischemic time of 90 minutes. The use of NHBD lungs to increase the donor pool has the potential to ameliorate the critical organ shortage without necessarily requesting a decrease of the currently accepted total ischemic time. Nevertheless, further investigations with extended observation periods are planned to determine the long-term graft function of NHBD lungs.

	Acknowledgments

 
We thank Annemarie Allmeling, Gudrun Hoebel, Sylvia Münzing, and Elke Schuetze for their technical expertise and excellent support during the laboratory studies. Furthermore, we thank Otto Frisch for the animal care and Rudolph A. Hatz, MD, for revising the manuscript.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Konrad F.W. Messmer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Loehe, F. Articles by Schildberg, F. W. Search for Related Content PubMed PubMed Citation Articles by Loehe, F. Articles by Schildberg, F. W.