normothermic ex situ porcine heart perfusion and coronary angiography for artery assessment

<meta charset="utf8"></head><body>Koronararterievurdering under ex-situ hjerteperfusion

Heart transplantation is the gold standard therapy for advanced heart failure1,2. However, this treatment is limited by the current organ shortage, leading to increased allocation of extended criteria donors (ECD), who are more frequently exposed to coronary artery disease (CAD). Coronary angiography is recommended in France to prevent the risk of primary graft failure related to CAD if the donor&#39;s age is greater than 55 years or 45 years with two cardiovascular risk factors3. Even though coronary angiography increases the chances of graft acceptance by 9%, this procedure is performed in only 33% of cases in France4. Hearts from ECD at risk for CAD are therefore either declined for transplant or procured without screening for coronary artery disease.
The Organ Care System (OCS) is the only clinically available machine perfusion (MP) for Normothermic Ex-situ heart perfusion (NESP). This technology allows for longer preservation before transplantation by perfusing the donor heart with warm, oxygenated blood. Continuous metabolic assessment is performed during NESP by monitoring the lactate profile5. The efficacy and safety of NESP are now demonstrated by several studies, including a recent meta-analysis6,7,8. Performing coronary angiography during NESP would be of major interest to increase the probability of transplanting hearts from ECDs at risk for CAD.
Previously published experiences of ex-situ coronary angiography9,10,11 suggest that conventional views are not suitable due to the inverted position of the heart in the perfusion module. In addition, OCS components visible with X-rays may impair imaging findings. Lastly, the toxicity of contrast agents on the myocardium during isolated heart perfusion remains questionable. The present report aims to provide a safe and reproducible approach to performing coronary angiography during NESP.

<meta charset="utf8"></head><body>Forfatter Spotlight: Innovativ teknik til koronar angiografi hos marginale donorer

Koronar angiografi under ex-situ hjerteperfusion i en svinemodel

Screening for coronary artery disease is recommended before heart procurement in marginal donors, but is often lacking. Performing a coronary angiographic ex-situ heart perfusion could be an alternative. This video provides a detailed description of this method.Nonconventional views are needed for coronary imaging since the heart is inverted in the perfusion module. Second, the components of the module can create artifacts for inadequate imaging. And last, the toxicity of contrast agent remains questionable since it's not eliminated from the perfusion module.Performing coronary angiography during ex-situ heart perfusion is easily reproducible and can extrude stenosis of the main coronary vessels. Coronary angiography on an insulated perfused heart is not a common procedure for an interventional cardiologist. Providing a detailed protocol of a reproducible views can help to reduce exposure to contrast agent, which can be harmful.A better assessment of coronary artery disease will increase the allocation of marginal grafts and could therefore reduce the organ shortage.

Normomic ex situ porcine hjerteperfusion og koronar angiografi til arterievurdering

normothermic-ex-situ-porcine-heart-perfusion-coronary-angiography-for

Research

JoVE Journal

Medicine

Normothermic Ex Situ Porcine Heart Perfusion and Coronary Angiography for Artery Assessment

Coronary Angiography During Ex-Situ Heart Perfusion in a Porcine Model

Heart transplantation is the gold standard treatment for advanced heart failure. The procurement of extended criteria donors (ECD) increases due to the current organ shortage. Coronary angiography is recommended in ECD at risk for coronary artery disease but is not systematically performed. These hearts are, therefore, either declined for transplant or procured without screening for coronary artery disease. Coronary angiography during normothermic ex-situ heart perfusion (NESP) could be an interesting approach to enhance the rate of ECD procurement and to reduce the risk of primary graft failure in the absence of coronary angiography in ECD. The present protocol aims to provide material details along with optimal imaging views for coronary angiography during NESP. Reproducible angiographic views were observed, including one dedicated to the right coronary artery, two for the left anterior descending artery, two for the circumflex artery, and a spider view. Continuous lactate extraction was observed in all procedures with a final median concentration of 1.10 mmol/L (0.61-1.75 mmol/L) two hours after coronary angiography, consistent with myocardial viability. The median contrast agent volume used for ex-situ imaging of the isolated perfused heart was 48 mL (38-108 mL). This protocol was reproducible for coronary artery imaging and did not impair myocardial viability during NESP.

Screening for coronary artery disease could increase the procurement of donor hearts with extended criteria. A protocol for performing reproducible coronary angiography during ex-situ heart perfusion is described herein in a porcine model.

Heart transplantation is the gold standard treatment for advanced heart failure. The procurement of extended criteria donors (ECD) increases due to the ...

To begin, use a scalpel to cut open the skin along the midline of an anesthetized pig. Open the subcutaneous tissue with a monopolar cautery. Then use a sternal saw to open the sternum.Dissect and open the thymus. With a pair of Metzenbaum scissors, expose the pericardium. Use 4-0 polypropylene sutures to perform purse string sutures on the right atrium and aortic root.Cannulate the right atrium with a 32 French two-stage venous cannula. Now, connect a previously heparinized sterilized bag to the right atrium cannula. Collect 1, 500 milliliters of blood.Clamp the aorta, then infuse 1000 milliliters of cold cardioplegia solution. Next, remove the aortic and venous cannulas. Section the left azygos vein, the two vena cavi, the distal ascending aorta, the pulmonary artery trunk, and the four pulmonary veins, to excise the heart.Place the heart in cold saline solution. Check the aortic valve to confirm normal coaptation. Place four pledgeted sutures around the distal section of the ascending aorta.Then, insert the appropriate aortic cannula and fix it with a hose clamp. Next, insert a 30 French pulmonary artery cannula. Secure it with a 4-0 purse string suture.Finally, place an intracardiac sump through the mitral orifice to vent the left ventricle. Elevate a perfusion machine by 25 centimeters with a platform. Rotate it 90 degrees to the left.Prime the perfusion machine with 500 milliliters of priming solution. Then, add 1, 500 milliliters of the collected porcine blood. Oxygenate the blood with a membrane oxygenator.Then, warm the blood to 34 degrees Celsius with a heater cooler. Collect an initial blood sample for blood gas analysis, ionogram and lactate level. Reduce the pump flow of the perfusion machine to 1000 milliliters per minute.Then remove the shunt between the aortic and venous lines. Now de-air the aorta. Connect the aortic cannula to the aortic line.Massage the heart gently until it is warmed. Place the heart for optimal normothermic XE to profusion. Use an external pacemaker to pace the heart at 80 beats per minute.Slowly increase the pump flow to an aortic pressure of 65 milliliters of mercury. Close the inferior vena cava with a 4-0 polypropylene running suture. Purge and connect the pulmonary artery cannula to the venous line to continuously assess coronary flow.Next, flush the five French introducer and the five French Judkins right 3.5 coronary angiography catheter with serum. Insert a five French introducer through the valved orifice of the machine. Advance the guide wire into the coronary angiography catheter up to the distal orifice.Then, perform a coronary angiography. Catheterize the right coronary artery using the given views. Then, capture the images of the right coronary artery, proximal right coronary artery and distal right coronary artery networks.Similarly, catheterize the left coronary artery and capture the images of the left anterior descending artery, spider view, and marginal coronary artery networks.