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Ann Thorac Surg 2000;69:912
© 2000 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, LSU Health Science Center, 1501 Kings Highway, Shreveport, LA 71130, USA
Invited commentary
This descriptive paper by Lick and colleagues is to my knowledge the first report using controlled reperfusion during human lung transplantation. Animal research has long demonstrated that in the lung, as in other solid organs, the injury seen after a period of ischemia, occurs to a large extent during reperfusion. It has subsequently been well documented that by modifying the conditions of reperfusion, the ischemia-reperfusion injury can be significantly decreased. However, the clinical application of this basic knowledge has been slow in developing. The methodology used in this paper was initially described by Halldorsson and colleagues [1, 2]. We showed, using a clinically relevant animal model, that by controlling the conditions during reperfusion, the lung function was significantly better preserved compared to uncontrolled reperfusion, as is currently the practice in human lung transplantation. We also showed that because of the complexity of the ischemia-reperfusion injury, different aspects of the reperfusion phase have to be modified, resulting in a fully controlled reperfusion. The key element in the reperfusion phase of this injury are white blood cells (WBC) activation, perfusion pressure and composition of the initial reperfusate. Each of these can be modified in different ways and controlled to a different level.
In our initial animal studies we chose to control the reperfusion in the following manner: A cannula was placed in a large artery and a small amount of blood was drawn from the animal and passed through a roller pump using a simple cardiopulmonary bypass tubing. The blood was modified by mixing it with a Buckberg solution and passed through a WBC filter. This modified leucocyte poor blood solution was then used to reperfuse the newly implanted lung using strict pressure control. The authors of this study have accepted our concept of fully controlled reperfusion and have nicely adapted our method for use in human lung transplantation.
Dr Lick and his associates have shown us in this paper that fully controlled reperfusion after human lung transplantation can easily be achieved using simple devices and equipment, already available in any operating room performing this operation. No additional manpower is needed and the increase in operating time is minimal. Although the number of patients is small, no significant complications have resulted and the clinical outcome, as far as reducing reperfusion injury, is very encouraging. Further clinical studies are obviously needed to validate this technique of reperfusion, assess potential complications and refine the methodology. Reducing the reperfusion injury will improve outcome compared to current practices, but also has the potential to increase the donor pool by allowing us to accept less ideal organs and tolerate longer ischemic times.
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