Forty-eight hours hypothermic pulsatile perfusion of canine hearts before transplantation.

Canine hearts preserved for 24 hr under hypothermic pulsatile perfusion had a good function after transplantation. The perfusate consisted of cryoprecipitated plasma that was modified by the addition of salt poor albumin, potassium chloride and glucose; the final osmolarity was 340 mOsm/L. Fresh allografts without perfusion survived for an average of two weeks after transplantation, and the 24 hr perfused hearts survived for more than 19 days after transplantation. When the perfusion was extended to 48 hr, the survival was decreased to 11 days. These data indicate that hypothermic pulsatile perfusion is completely safe and feasible for 24 hr without significant functional or histological impairment. The survival response of the hearts perfused for 48 hr was significantly decreased when compared to the hearts perfused for 24 hr.     

Improved cardiac function following hormonal therapy in brain dead pigs: relevance to organ donation

Deterioration of function in brain dead baboons is associated with depletion of both myocardial energy stores and certain circulating hormones, notably thyroxine, cortisol, and insulin. We have therefore investigated the effect of the administration of these three hormones to the brain dead pig; their value has been assessed on both the freshly excised and stored donor heart. Brain death was induced by ligation of the two arteries to the upper part of the body which arise from the aortic arch. Storage of selected hearts was by continuous hypothermic perfusion for 20 to 24 hr. Hearts were biopsied for estimation of adenosine triphosphate, creatine phosphate, lactate, and glycogen, and were subsequently functionally tested. Six groups of pigs were studied. Hearts were tested from control pigs which had not undergone brain death (A1), from brain dead pigs which had received intravenous fluid and inotropic support for 4 hr (B1), and from brain dead pigs which had in addition received 2 hr of hormonal therapy (thyroxine 2 micrograms cortisol 100 mg, and insulin 5-10 IU hourly) (C1). A further 3 groups (A2-C2) underwent management identical to A1-C1, but in addition the hearts were stored for 24 hr. Brain death in pigs was followed by a consumption of myocardial energy stores, despite anaerobic glycolysis; this was associated with reduced myocardial function. The administration of hormones to the brain dead pig led to some replenishment of myocardial energy and glycogen reserves and reduction in lactate, with associated improvement in hemodynamic function. A period of hypothermic perfusion storage appeared to reverse the anaerobic metabolism occurring in the heart in the nonhormonally treated brain dead animal, though not in the hormonally treated animal, and led to replenishment of glycogen reserves in nontreated animals. The observation that both better function and an increase in myocardial energy stores occurred in hormonally treated, stored hearts, even though perfusate lactate dehydrogenase rose to significantly higher levels during hypothermic perfusion storage, and tissue lactate levels remained high, suggests that thyroxine promotes both aerobic and anaerobic metabolism in brain dead animals.     

An airlift pump device for low pressure perfusion storage of the isolated heart

A portable apparatus for the continuous hypothermic perfusion of the isolated heart is described. The system has been used successfully to store pig and baboon hearts for periods of up to 48 hr, and to store human donor hearts for periods of 7 to 17 hr before being transplanted. The perfusate is both oxygenated and circulated by gas flow from a pressurized oxygen cylinder, using the air-lift pump principle. The apparatus has no moving parts and requires no electrical energy supply; malfunction is, therefore, extremely unlikely. A regulator has been incorporated which can be adjusted to increase or decrease the myocardial perfusion pressure. The system and environmental variables which can affect flow and pressure within the apparatus are discussed. The storage time allowed by this system will enable transportation of donor hearts between most of the world's major cities.     

Hypothermic preservation of the rat heart. Comparison of immersion and low-flow perfusion methods: contribution of 31P-NMR spectroscopy

Comparison of rat heart preservation by simple storage in a cardioplegic solution at 4 degrees C (6 hr for group I; 15 hr for group II) and by hypothermic low-flow perfusion of the same solution (0.3 ml min-1, 15 hr: group III) was performed by measuring biochemical and functional parameters and by collecting 31P-NMR spectroscopy data. When compared to control values, adenine nucleotide levels remained unchanged in group I hearts, while glycogen was 45% hydrolyzed and lactate level increased by 700%. Extension of heart immersion to 15 hr (group II) led to breakdown of ATP (-77%), of the sum of adenine nucleotides (-27%), and of glycogen (-77%), whereas lactate accumulation reached 900% of the control value. Functional recovery, measured at the end of a 60-min reperfusion was less than 10% in group II hearts when compared to group I hearts. This dramatic development was completely avoided by hypothermic low-flow perfusion (group III). 31P-NMR data showed that phosphocreatine was completely degraded in all groups of preserved hearts. Low-flow perfusion limited cellular acidosis. The ATP/Pi (Pi = inorganic phosphate) ratio calculated from NMR data was lower for group II hearts (0.04 +/- 0.01, n = 6) than for group I hearts (0.29 +/- 0.12; n = 6) or group III hearts (0.19 +/- 0.09; n = 6) and could constitute a convenient bioenergetic index to predict the capability of the heart to recover satisfactory contractility following a preservation period.     

Silica-free silicone rubber in isolated heart perfusion with blood at 13 °C

Isolated lamb hearts were perfused at 13 °C for 24 hr with whole fresh blood using a silicone rubber circuit and a membrane lung (N = 7); there was formation of thrombi, deposition of fibrin, and an increase in resistance to blood flow in the membrane lung. The perfused hearts fibrillated at hypothermia and showed unequal recovery of function upon final rewarming.There was less rise in membrane lung resistance when the perfusion circuit was primed with blood at 38 instead of 13 °C and then cooled progressively to 13 °C. Some hearts perfused in these circuits were well preserved but others became edematous with loss of ventricular contractility (N = 6).Coating the perfusion circuit with a hypothrombogenic material, silica-free silicone rubber and priming the circuit at 38 °C prevented any rise in membrane lung resistance during blood perfusion. All the hearts perfused in these circuits (N = 6) had the same left ventricular function before and after cold perfusion.Thus isolated hearts can be perfused in vitro with whole blood at hypothermic temperature without loss in function when attention is paid to thrombogenicity of materials used to construct the perfusion circuit.     

Isolated sheep heart hypothermic (5–13 °C) perfusion with fresh blood: Successful preservation for 24–72 hours with continuous strong ventricular activity

Isolated lamb hearts perfused with fresh whole blood at 10 and 13 °C in an ex vivo perfusion circuit continuously contracted at a rate of 15 to 20 times/min with a peak left ventricular systolic pressure (LVPSP) up to 70 mm Hg. These contractions persisted for the duration of the hypothermic study, up to three days with no change in vascular resistance. On rewarming to 38 °C, the hearts resumed regular and efficient contractions. Hearts perfused at 5 °C, however, exhibited no electrical or mechanical activity during hypothermic preservation and were uniformly poorly preserved.Quality of heart preservation was improved if, prior to final cooling, hearts were first rewarmed to 38 °C, followed by cooling. Change of the support animal, or interruption of flow of fresh blood into the perfusion circuit, resulted in cessation of ventricular contractions, ventricular fibrillation, and poor organ preservation.     

Alteration in the distribution of organ perfusion following profound hypothermia and circulatory arrest in the baboon.

The physiologic consequences of profound hypothermic circulatory arrest in infants are incompletely understood. Immature baboons underwent surface cooling, followed by core cooling using cardiopulmonary bypass, circulatory arrest for 30 min, and perfusion rewarming. Blood flow to and within organs was studied using the multiple-radionuclide-label microsphere technique. Marked redistribution of total and regional myocardial and cerebral flow occurred during cooling and rewarming.     

Cold storage preservation of islet and pancreas grafts as assessed by in vivo function after transplantation to diabetic hosts

The major goal of hypothermic (4–8 °C) preservation of intact pancreases or isolated islets will be to provide sufficient time for HLA typing, cross matching, selection, and preparation of recipients—logistical efforts requiring 12–72 hr for clinical kidney transplantation, usually <48 hours. Some investigators have studied in vitro function of islets after cold storage, but the critical test of viability—permanent restoration of normoglycemia after transplantation to diabetic recipients—has been tested in only a few experiments. Reversal of hyperglycemia by syngeneic or autogenic transplants in diabetic animals has been achieved after CS of dispersed pancreatic tissue from neonatal rats in GIB media for ? 146 hr, adult dogs in TCM 199 for ?24 hr, and adult DL-ethionine-treated rats in RPMI 1640 for ?72 hr. In the neonatal rat donor model, intravenous glucose tolerance test (IVGTT) results were similar in recipients of fresh or stored islets; in the dog model, IVGTT test results were variable, but generally inferior in recipients of stored as compared to fresh islets; in the adult rat donor model, recipients of ?24-hr coldstorage islets had insulin and IVGTT K values similar to those of recipients of fresh islets, but the success rate progressively declined for CS times >24 hr. Various agents were added to the media, but the need or the optimal concentrations were not critically determined by using different recipes for different groups of recipients. Cold storage of intact pancreas autografts has been tested in dogs; simple electrolyte solutions are satisfactory for 24 hr, but only a silica gel-filtered plasma-based solution has been reliable for 48 hr. Pulsatile machine perfusion (PMP) of canine pancreas grafts for 24 hr has had a success rate similar to CS in some experiments and lower in others. PMP has been almost totally unreliable for >24 hr. Further refinements are needed if preservation of islets for >24 hr and pancreases for >48 hr are to be consistently successful. If current experimental techniques are effective for human islets or pancreases, however, these times are sufficient to complete the logistical maneuvers required before transplantation.     

Renal preservation by hypothermic perfusion. I. The importance of pressure-control

Rabbit kidneys were preserved by hypothermic perfusion at 5 °C using a perfusate containing an extracellular balance of ions, dextran and bovine serum albumin. Two groups were studied: in one, the pressure was kept constant at 40 mm Hg, while in the other the flow was maintained at 13 ml/min. The mean flows in the two groups were similar but the resistance of the kidneys perfused under constant-flow conditions was lower and more stable: the vascular resistance in the constant-pressure group showed considerable fluctuations throughout the 24 hr perfusion period. The function of the kidneys was assessed by autotransplantation with immediate contralateral nephrectomy. The constant-pressure group functioned better in all respects: the proportion of animals surviving was higher, the postoperative blood urea and creatinine levels were lower, and histological examination of the kidneys revealed less damage. It is concluded that constantpressure perfusion should be preferred to constant-flow perfusion. These experiments confirmed that there is a correlation between potassium release into the perfusate and subsequent function, and an unexpected inverse correlation was observed between the perfusate glucose level and subsequent function. Possible reasons for this are discussed.     

The hypothermic hamster brain: Its water and electrolyte content and perfusion

The data suggest that cold swelling of the brain does not occur in hypothermic hamsters for up to 48 hr or in the hypothermic rat for 2 hr. It may be possible that the adaptation of the Na⁺,K⁺-activated ATPase system as well as lipid changes occurs during the 6- to 8-hr induction period of hypothermia in the hamster. The absence of swelling in the rat, a species which does not hibernate, may be due to both the lack of hypercapnia and the brevity of the hypothermic period. It is noteworthy that in the hamster the distribution of cardiac output to the brain and the respiratory centers of the brain system is unaffected by hypothermia of up to 18 hr. Actual perfusion is, however, dramatically reduced. The data suggest that the helium-cold hypothermic hamster retains the ability to maintain solute gradients in hypothermia, and that hypothermic death is not due to an increase in cerebral water content or in the percentage of cardiac output received by the brain.     

Influence of short-term hypothermia upon the normal or ischaemic dog kidney.

Dog kidneys were subjected to 1 hr of normothermic ischaemia, maintained for 3 hr in hypothermia with autologous heparinised blood, or underwent a combination of these two treatments and were examined either immediately after the trauma or at different periods up to 1 week after autotransplantation. Clearance tests, tubular amino acid and sugar transport, cortical Na⁺K⁺-ATPase levels, acid phosphatase liberated into the renal circulation, and morphology were investigated. The results obtained (i) confirmed the severe, but slowly and progressively reversible lesion after ischaemia; (ii) revealed the functional impairment with almost normal morphology after hypothermia; and (iii) indicated the immediate and irreparable deterioration of renal function after ischaemic kidneys were subjected to short-term hypothermic treatment of this type.     

Successful 96- and 144-hour experimental kidney preservation: A combination of standard machine preservation and newly developed normothermic ex vivo perfusion

In order to enable time-consuming matching and selection procedures (PLT, MLC) in kidney transplantation, a new approach to prolonged kidney preservation was studied. In a canine autotransplantation and contralateral nephrectomy model hypothermic machine preservation was interrupted by a short period of ex vivo perfusion on the donor animal. In a 96-hr experiment post-transplantation serum creatinines were significantly lower in the ex vivo perfused group versus the control group. All animals survived. In a 144-hr study five out of six survived in the ex vivo perfused group as opposed to one out of six in the control group. The beneficial effect of this ex vivo perfusion in the course of hypothermic machine preservation may be due either to a washout of metabolic waste products or to a restoration of exhausted enzyme systems.     

Preservation of guinea pig hearts by hypothermic gas perfusion

The lack of a satisfactory method for long-term preservation of hearts during transport limits the source of human hearts for transplant to the geographic vicinity of the transplant center. Experimentally, reduction of myocardial oxygen requirements with hypothermia and cardioplegia prolong storage time to 48 h, but always with some evidence of myocardial damage. In this study, the combination of hypothermia with a procedure known to increase oxygen tension in cardiac muscle, gas perfusion, preserved contractile activity in guinea pig hearts for 24 h and did not cause edema. Cardioplegia or gas perfusion at temperatures below 10 degrees C or above 20 degrees C resulted in failure of hearts to contract upon rewarming. Contracture, dehydration, elevation of tissue calcium, reduced perfusate flow, and elevated creatine kinase levels occurred if liquid reperfusion was begun at 15 degrees C but not 25 degrees C. The results suggest that under the appropriate conditions, hypothermic gas perfusion is a potentially useful means of extending storage time of hearts for transplant.     

Protective effect of a low K+ cardioplegic solution on myocardial Na,K-ATPase activity.

Long duration ischemia in hypothermic conditions followed by reperfusion alters membrane transport function and in particular Na,K-ATPase. We compared the protective effect of two well-described cardioplegic solutions on cardiac Na,K-ATPase activity during reperfusion after hypothermic ischemia. Isolated perfused rat hearts (n = 10) were arrested with CRMBM or UW cardioplegic solutions and submitted to 12 hr of ischemia at 4 degrees C in the same solution followed by 60 min of reperfusion. Functional recovery and Na,K-ATPase activity were measured at the end of reperfusion and compared with control hearts and hearts submitted to severe ischemia (30 min at 37 degrees C) followed by reflow. Na,K-ATPase activity was not altered after 12 hr of ischemia and 1 hr reflow when the CRMBM solution was used for preservation (55 +/- 2 micromolPi/mg prot/hr) compared to control (53 +/- 2 micromol Pi/mg prot/hr) while it was significantly altered with UW solution (44 +/- 2 micromol Pi/mg prot/hr, p < 0.05 vs control and CRMBM). Better preservation of Na,K-ATPase activity with the CRMBM solution was associated with higher functional recovery compared to UW as represented by the recovery of RPP, 52 +/- 12% vs 8 +/- 5%, p < 0.05 and coronary flow (70 +/- 2% vs 50 +/- 8%, p < 0.05). The enhanced protection provided by CRMBM compared to UW may be related to its lower K+ content.     

Effects of chlorpromazine and methylprednisolone on perfusion preservation of rabbit livers

The isolated perfused rabbit liver was used to determine how continuous hypothermic perfusion affected liver function. Rabbit livers were perfused for 0, 24, 48, and 72 hr at 5 degrees C with the UW perfusate containing hydroxyethyl starch (5 g%) dissolved in a solution containing gluconate (80 mM), adenosine (5 mM), glutathione (3 mM), phosphate (25 mM), and additives as described previously, and they were used successfully for kidney preservation. At the end of preservation the livers were perfused in an isolated circuit with a Krebs-Henseleit solution with addition of 4 g% bovine serum albumin and 10 mM glucose at 38 degrees C for 120 min. Bile was collected from the cannulated common duct. Biliary excretions of indocyanine green and liver enzymes lactate dehydrogenase, aspartate aminotransferase, and alanine aminotransferase, were determined both in the cold perfusate and the normothermic perfusate. Livers were also studied after pretreatment of the donor with chlorpromazine (CPZ) and/or methylprednisolone (MP). Bile production (ml/120 min, 100 g liver) upon reperfusion produced the most interesting data and decreased from a control value of 10.3 +/- 2.6 to 9.3 +/- 1.0 (24 hr), 5.3 +/- 0.7 (48 hr), and 4.1 +/- 1.5 (72 hr). Enzyme release was not predictive of the degree of preservation-induced damage. Pretreatment of rabbits with a combination of CPZ/MP improved bile flow at 48 and 72 hr (8.3 +/- 3.0 and 7.0 +/- 1.3, P less than 0.05). Pretreatment with either drug alone also improved function after 72 hr of preservation (7.1 +/- 1.8, CPZ; 8.2 +/- 3.5, MP).(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of the effects of adenine-ribose with adenosine for maintenance of ATP concentrations in 5-day hypothermically perfused dog kidneys

The quality of preservation of kidneys is dependent upon a number of factors, one of which may be the concentration of adenine nucleotides in the tissue during long-term perfusion preservation. In this study we have investigated how adenine (5 mM) and ribose (5 mM) in combination affect the concentration of adenine nucleotides in dog kidney cortical tissue after 5 days of continuous hypothermic perfusion preservation. These results were compared to kidneys perfused with adenosine and without any added purine precursors of adenine nucleotide synthesis. Additionally, we investigated how these conditions affected renal tissue slice function after 5 days of preservation and how adenine plus ribose affected renal function after autotransplantation in the dog. Adenosine is nearly completely degraded during 5 days of perfusion but there was little loss of adenine (10%). The adenosine triphosphate concentration in kidney cortical tissue was higher in adenine/ribose-perfused kidneys (1.41 +/- 0.19 mumol/g) than in adenosine-perfused kidneys (0.71 +/- 0.1 mumol/g) after 5 days of preservation. Tissue slices prepared from kidneys preserved in the presence of adenine plus ribose were metabolically more functional (slice volume control and electrolyte pump activity) than slices from adenosine-perfused kidneys. Adenine plus ribose had no detrimental effects on kidneys preserved for 3 days as tested in the autotransplant model but did not yield successful 5-day preservation. Because of some potentially detrimental factors in using adenosine as an adenine nucleotide synthesis precursor, we have now switched to the combination of adenine and ribose for perfusion preservation of kidneys both in the laboratory and in the clinic.     

Analysis of population cytokinetics of chick myocardial cells in tissue culture

The growth of embryonic chick cardiac myocytes and fibroblasts in tissue culture was evaluated by the kinetics of nuclear labeling during continuous exposure to [3H]thymidine. The fraction of mitotically active cells, the mean intermitotic period and the population doubling times were determined in each cell type during 3 weeks in culture. After 24 hr in culture, 90% of the muscle cells were mitotically active with minimal population doubling times of 65 hr. By 17 days in culture only 5% of the myocytes continued to divide with population doubling times greater than 3000 hr. Primarily, the lengthening of doubling times was due to a withdrawal of cells from the mitotic cycle and much less to a lengthening of the intermitotic period. Growth of cardiac muscle cells from embryonic hearts from 4 to 10 days of development was also compared. Muscle cells from younger hearts displayed greater mitotic activity than those from older hearts at equivalent times in culture.     

Acidosis protection during 24-hour ischemic heart preservation.

Puppies' hearts were preserved under hypothermic ischemic conditions. They were initially flushed with an intracellular type solution. It was shown that ATP stores were better maintained if the fluid was acid. The level of ATP at the end of 24 hr is compatible with recovery. In these conditions, the study of lactate production and tissue pH seems to indicate that it is due to a slower ATP decrease rate. The pH of the perfusate might act at the extracellular side of the myocardial cell.If hearts were reperfused after such a preservation, they resumed a sinus rhythm and strong contraction after isoproterenol infusion.     

Persufflation (or gaseous oxygen perfusion) as a method of organ preservation

Improved preservation techniques have the potential to improve transplant outcomes by better maintaining donor organ quality and by making more organs available for allotransplantation. Persufflation, (PSF, gaseous oxygen perfusion) is potentially one such technique that has been studied for over a century in a variety of tissues, but has yet to gain wide acceptance for a number of reasons. A principal barrier is the perception that ex vivo PSF will cause in vivo embolization post-transplant. This review summarizes the extensive published work on heart, liver, kidney, small intestine and pancreas PSF, discusses the differences between anterograde and retrograde PSF, and between PSF and other conventional methods of organ preservation (static cold storage, hypothermic machine perfusion). Prospective implications of PSF within the broader field of organ transplantation, and in the specific application with pancreatic islet isolation and transplant are also discussed. Finally, key issues that need to be addressed before PSF becomes a more widely utilized preservation strategy are summarized and discussed.     

Preservation of Isolated Heart for 72 Hours

Isolated hearts of dogs have been preserved in a viable condition for 72 hours with hypothermic perfusion (5° C.) at normal atmospheric pressure. On removal and connexion to the femoral artery and vein of another dog these hearts beat strongly and without failing until removed after six hours. In mechanical function and histological appearance they were virtually identical with control hearts. The most useful criterion of viability of the quiescent myocardium during storage was the change in coronary resistance with time of perfusion.