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This paper describes a porcine model of negative pressure ventilation ex situ lung perfusion, including procurement, attachment, and management on the custom-made platform. Focus is made on anesthetic and surgical techniques, as well as troubleshooting.
Lung transplantation (LTx) remains the standard of care for end-stage lung disease. A shortage of suitable donor organs and concerns over donor organ quality exacerbated by excessive geographic transportation distance and stringent donor organ acceptance criteria pose limitations to current LTx efforts. Ex situ lung perfusion (ESLP) is an innovative technology that has shown promise in attenuating these limitations. The physiologic ventilation and perfusion of the lungs outside of the inflammatory milieu of the donor body affords ESLP several advantages over traditional cold static preservation (CSP). There is evidence that negative pressure ventilation (NPV) ESLP is superior to positive pressure ventilation (PPV) ESLP, with PPV inducing more significant ventilator-induced lung injury, pro-inflammatory cytokine production, pulmonary edema, and bullae formation. The NPV advantage is perhaps due to the homogenous distribution of intrathoracic pressure across the entire lung surface. The clinical safety and feasibility of a custom NPV-ESLP device have been demonstrated in a recent clinical trial involving extender criteria donor (ECD) human lungs. Herein, the use of this custom device is described in a juvenile porcine model of normothermic NPV-ESLP over a 12 h duration, paying particular attention to management techniques. Pre-surgical preparation, including ESLP software initialization, priming, and de-airing of the ESLP circuit, and the addition of anti-thrombotic, anti-microbial, and anti-inflammatory agents, is specified. The intraoperative techniques of central line insertion, lung biopsy, exsanguination, blood collection, cardiectomy, and pneumonectomy are described. Furthermore, particular focus is paid to anesthetic considerations, with anesthesia induction, maintenance, and dynamic modifications outlined. The protocol also specifies the custom device's initialization, maintenance, and termination of perfusion and ventilation. Dynamic organ management techniques, including alterations in ventilation and metabolic parameters to optimize organ function, are thoroughly described. Finally, the physiological and metabolic assessment of lung function is characterized and depicted in the representative results.
Lung transplantation (LTx) remains the standard of care for end-stage lung disease1; however, LTx has significant limitations including inadequate donor organ utilization2 and a waitlist mortality of 40%3, which is higher than any other solid organ transplant4,5. Donor organ utilization rates are low (20-30%) due to organ quality concerns. Excessive geographic transportation distance compounded by stringent donor organ acceptance criteria exacerbates these quality concerns. LTx also trails other solid organ transplants in terms of long-ter....
The procedures performed in this manuscript comply with the guidelines of the Canadian Council on Animal Care and the guide for the care and use of laboratory animals. The institutional animal care committee of the University of Alberta approved the protocols. Female juvenile Yorkshire pigs between 35-50 kg were used exclusively. Proper biosafety training was required by all individuals involved in ESLP procedures. A schematic overview of the entire NPV-ESLP experiment is represented in Figure 1
At the beginning of lung perfusion and ventilation (preservation mode), the lungs will generally have a low pulmonary artery pressure (< 10 mmHg) and low dynamic compliance (< 10 mL/mmHg) as the perfusate warms to normothermia. Yorkshire pigs weighing 35-50 kg typically results in lungs weighing 350-500 g. During the first hour of NPV-ESLP, the measured expiratory tidal volumes (TVe) are 0-2 mL/kg, and the inspiratory tidal volumes (TVi) are 100-200 mL. TVe generally reaches 4-6 mL/kg within 3-6 h, and after that.......
There are several critical surgical steps along with troubleshooting needed to ensure a successful ESLP run. Juvenile porcine lungs are extremely delicate compared to adult human lungs, so the procuring surgeon must be cautious when handling porcine lungs. It is critical to attempt a "no-touch" technique to avoid causing trauma and atelectasis when dissecting out the lungs. "No-touch" means using the bare minimum amount of manual manipulation of the lungs during procurement. Recruitment maneuvers while on.......
This research was funded on behalf of The Hospital Research Foundation.
....Name | Company | Catalog Number | Comments |
0 ETHIBOND Green 1 x 36" Endo Loop 0 | ETHICON | D8573 | |
2-0 SILK Black 12" x 18" Strands | ETHICON | SA77G | |
ABL 800 FLEX Blood Gas Analyzer | Radiometer | 989-963 | |
Adult-Pediatric Electrostatic Filter HME - Small | Covidien | 352/5877 | |
Arterial Filter | SORIN GROUP | 01706/03 | |
Backhaus Towel Clamp | Pilling | 454300 | |
Biomedicus Pump | Maquet | BPX-80 | |
Cable Ties – White 12” | HUASU International | HS4830001 | |
Calcium Chloride | Fisher Scientific | C69-500G | |
Cooley Sternal Retractor | Pilling | 341162 | |
CUSHING Gutschdressing Forceps | Pilling | 466200 | |
D-glucose | Sigma-Aldrich | G5767-500G | |
Deep Deaver Retractor | Pilling | 481826 | |
Debakey Straight Vascular Tissue Forceps | Pilling | 351808 | |
Debakey-Metzenbaum Dissecting | Pilling | 342202 | |
Scissors | Pilling | 342202 | |
Endotracheal Tube 9.0mm CUFD | Mallinckrodt | 9590E | Cuff removed for ESLP apparatus |
Flow Transducer | BIO-PROBE | TX 40 | |
Human Albumin Serum | Grifols Therapeutics | 2223708 | |
Infusion Pump | Baxter | AS50 | |
Inspire 7 M Hollow Fiber Membrane Oxygenator | SORIN GROUP | K190690 | |
Intercept Tubing 1/4" x 1/16" x 8' | Medtronic | 3108 | |
Intercept Tubing 3/8" x 3/32" x 6' | Medtronic | 3506 | |
Intercept Tubing Connector 3/8" x 1/2" | Medtronic | 6013 | |
MAYO Dissecting Scissors | Pilling | 460420 | |
Medical Carbon Dioxide Tank | Praxair | 5823115 | |
Medical Nitrogen Tank | Praxair | NI M-K | |
Medical Oxygen Tank | Praxair | 2014408 | |
Organ Chamber | Tevosol | ||
PlasmaLyte A | Baxter | TB2544 | |
Poole Suction Tube | Pilling | 162212 | |
Potassium Phosphate | Fischer Scientific | P285-500G | |
Scale | TANITA | KD4063611 | |
Silicon Support Membrane | Tevosol | ||
Sodium Bicarbonate | Sigma-Aldrich | 792519-1KG | |
Sodium Chloride 0.9% | Baxter | JB1324 | |
Sorin XTRA Cell Saver | SORIN GROUP | 75221 | |
Sternal Saw | Stryker | 6207 | |
Surgical Electrocautery Device | Kls Martin | ME411 | |
Temperature Sensor probe | Omniacell Tertia Srl | 1777288F | |
THAM Buffer | Thermo Fisher Scientific | 15504020 | made from UltraPureTM Tris |
TruWave Pressure Transducer | Edwards | VSYPX272 | |
Two-Lumen Central Venous Catheter 7fr | Arrowg+ard | CS-12702-E | |
Vorse Tubing Clamp | Pilling | 351377 | |
Willauer-Deaver Retractor | Pilling | 341720 | |
Yankauer Suction Tube | Pilling | 162300 |
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