Name: normothermic negative pressure ventilation ex situ lung perfusion: evaluation of lung function and metabolism
Uploaded: 2022-02-14T14:00:00
Description: Watch this Scientific Journal Video about Normothermic Negative Pressure Ventilation Ex Situ Lung Perfusion: Evaluation of Lung Function and Metabolism at JoVE.com

This research was funded on behalf of The Hospital Research Foundation.

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</str...

<ol>
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C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+international+thoracic+organ+transplant+registry+of+the+international+society+for+heart+and+lung+transplantation:+Thirty-fifth+adult+lung+and+heart-lung+transplant+report-2018;+focus+theme:+Multiorgan+transplantation.">The international thoracic organ transplant registry of the international society for heart and lung transplantation: Thirty-fifth adult lung and heart-lung transplant report-2018; focus theme: Multiorgan transplantation.</a> The Journal of Heart and Lung Transplantation. 37 (10), 1169-1183 (2018).</li><li>Valapour, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=OPTN/SRTR+2017+annual+data+report:+Lung.">OPTN/SRTR 2017 annual data report: Lung.</a> American Journal of Transplantation. 19, 404-484 (2019).</li><li>Chambers, D. 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R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Liberalization+of+donor+criteria+may+expand+the+donor+pool+without+adverse+consequence+in+lung+transplantation.">Liberalization of donor criteria may expand the donor pool without adverse consequence in lung transplantation.</a> The Journal of Heart and Lung Transplantation. 19 (12), 1199-1204 (2000).</li><li>Snell, G. I., Griffiths, A., Levvey, B. J., Oto, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Availability+of+lungs+for+transplantation:+Exploring+the+real+potential+of+the+donor+pool.">Availability of lungs for transplantation: Exploring the real potential of the donor pool.</a> The Journal of Heart and Lung Transplantation. 27 (6), 662-667 (2008).</li><li>Cypel, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Normothermic+ex+vivo+lung+perfusion+in+clinical+lung+transplantation.">Normothermic ex vivo lung perfusion in clinical lung transplantation.</a> The New England Journal of Medicine. 364 (15), 1431-1440 (2011).</li><li>Wallinder, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Early+results+in+transplantation+of+initially+rejected+donor+lungs+after+ex+vivo+lung+perfusion:+A+case-control+study.">Early results in transplantation of initially rejected donor lungs after ex vivo lung perfusion: A case-control study.</a> European Journal of Cardio-Thoracic Surgery. 45 (1), 40-45 (2014).</li><li>Cypel, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Experience+with+the+first+50+ex+vivo+lung+perfusions+in+clinical+transplantation.">Experience with the first 50 ex vivo lung perfusions in clinical transplantation.</a> The Journal of Thoracic and Cardiovascular Surgery. 144 (1), 1200-1206 (2012).</li><li>Buchko, M. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+parenteral+nutrition+in+ex+vivo+lung+perfusion:+Addressing+metabolism+improves+both+inflammation+and+oxygenation.">Total parenteral nutrition in ex vivo lung perfusion: Addressing metabolism improves both inflammation and oxygenation.</a> American Journal of Transplantation. 19 (12), 3390-3397 (2019).</li><li>Andreasson, A. S. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Profiling+inflammation+and+tissue+injury+markers+in+perfusate+and+bronchoalveolar+lavage+fluid+during+human+ex+vivo+lung+perfusion.">Profiling inflammation and tissue injury markers in perfusate and bronchoalveolar lavage fluid during human ex vivo lung perfusion.</a> European Journal of Cardio-Thoracic Surgery. 51 (3), 577-586 (2017).</li><li>Sadaria, M. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cytokine+expression+profile+in+human+lungs+undergoing+normothermic+ex-vivo+lung+perfusion.">Cytokine expression profile in human lungs undergoing normothermic ex-vivo lung perfusion.</a> The Annals of Thoracic Surgery. 92 (2), 478-484 (2011).</li><li>Ricard, J. D., Dreyfuss, D., Saumon, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ventilator-induced+lung+injury.">Ventilator-induced lung injury.</a> European Respiratory Journal. 42, 2-9 (2003).</li><li>Aboelnazar, N. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Negative+pressure+ventilation+decreases+inflammation+and+lung+edema+during+normothermic+ex-vivo+lung+perfusion.">Negative pressure ventilation decreases inflammation and lung edema during normothermic ex-vivo lung perfusion.</a> The Journal of Heart and Lung Transplantation. 37 (4), 520-530 (2018).</li><li>Lai-Fook, S. J., Rodarte, J. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pleural+pressure+distribution+and+its+relationship+to+lung+volume+and+interstitial+pressure.">Pleural pressure distribution and its relationship to lung volume and interstitial pressure.</a> Journal of Applied Physiology. 70 (3), 967-978 (1991).</li><li>Buchko, M. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+transplantation+using+negative+pressure+ventilation+ex+situ+lung+perfusion+with+extended+criteria+donor+lungs.">Clinical transplantation using negative pressure ventilation ex situ lung perfusion with extended criteria donor lungs.</a> Nature Communications. 11 (1), 5765 (2020).</li><li>Buchko, M. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+low-cost+perfusate+alternative+for+ex+vivo+perfusion.">A low-cost perfusate alternative for ex vivo perfusion.</a> Transplantation Proceedings. 52 (10), 2941-2946 (2020).</li><li>Forgie, K. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left+lung+orthotopic+transplantation+in+a+juvenile+porcine+model+for+ESLP.">Left lung orthotopic transplantation in a juvenile porcine model for ESLP.</a> The Journal of Visualized Experiments. , (2021).</li></ol>

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 &#34;no-touch&#34; technique to avoid causing trauma and atelectasis when dissecting out the lungs. &#34;No-touch&#34; means using the bare minimum amount of manual manipulation of the lungs during procurement. Recruitment maneuvers while on...

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-term graft and patient outcomes2. Primary graft dysfunction (PGD), most often caused by ischemic reperfusion injury (IRI), represents the leading cause of 30-day mortality and morbidity post-LTx and increases the risk for chronic graft dysfunction6,7. Efforts to decrease IRI and extend safe transport times are paramount to improve patient outcomes.
Ex situ lung perfusion (ESLP) is an innovative technology that has shown promise in attenuating these limitations. ESLP facilitates the preservation, assessment, and reconditioning of donor lungs before transplantation. It has exhibited satisfactory short- and long-term outcomes following transplantation of extended criteria donor (ECD) lungs, contributing to an increase in the number of suitable donor lungs for LTx, with organ utilization rates increasing by 20% in some centres8,9,10. Compared to the current clinical standard for LTx, cold static preservation (CSP), ESLP offers several advantages: organ preservation time is not limited to 6 h, evaluation of organ function is possible before implantation, and due to continuous organ perfusion, modifications can be made to the perfusate that optimizes organ function11.
The vast majority of current ESLP devices designed for human use utilize positive pressure ventilation (PPV); however, recent literature has indicated that this ventilation strategy is inferior to negative pressure ventilation (NPV) ESLP, with PPV inducing more significant ventilator-induced lung injury12,13,14,15. In both human and porcine lungs, NPV-ESLP exhibits superior organ function when compared to positive pressure ex situ lung perfusion (PPV-ESLP) across various physiological domains, including pro-inflammatory cytokine production, pulmonary edema, and bullae formation15. The homogenous distribution of intrathoracic pressure across the entire lung surface in NPV-ESLP has been suggested as a significant factor underlying this advantage15,16. In addition to its pre-clinical benefits, the clinical safety and feasibility of NPV-ESLP have been demonstrated in a recent clinical trial17. Utilizing a novel NPV-ESLP device, twelve extended criteria donor human lungs were successfully preserved, evaluated, and subsequently transplanted with 100% 30-day and 1-year survival.
The objective of the present manuscript is to demonstrate a working protocol of our lab&#39;s NPV-ESLP device using juvenile porcine lungs under normothermic conditions for 12 h of duration. The surgical retrieval is covered in detail, and our custom software platform&#39;s initiation, management, and termination are also described. The strategy for tissue collection and the management of the samples is also explained.

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normothermic negative pressure ventilation ex situ lung perfusion: evaluation of lung function and metabolism

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.

At the beginning of lung perfusion and ventilation (preservation mode), the lungs will generally have a low pulmonary artery pressure (&#60; 10 mmHg) and low dynamic compliance (&#60; 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...

Watch this Scientific Journal Video about Normothermic Negative Pressure Ventilation Ex Situ Lung Perfusion: Evaluation of Lung Function and Metabolism at JoVE.com

Normothermic Negative Pressure Ventilation Ex Situ Lung Perfusion: Evaluation of Lung Function and Metabolism

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.

Normothermic Negative Pressure Ventilation Ex Situ Lung Perfusion: Evaluation of Lung Function and Metabolism

Lung transplantation (LTx) remains the standard of care for end-stage lung disease. A shortage of suitable donor organs and concerns over donor organ ...

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Lung Rapid Recovery Procurement Combined with Abdominal Normothermic Regional Perfusion in Controlled Donation after Circulatory Death

Controlled donation after circulatory death (cDCD) has contributed to increasing donor numbers all over the world. Experiences published in the last years ...

Functional Assessment of the Donor Heart During Ex Situ Perfusion: Insights from Pressure-Volume Loops and Surface Echocardiography

Functional Assessment of the Donor Heart During Ex Situ Perfusion: Insights from Pressure-Volume Loops and Surface Echocardiography

Heart transplantation remains the gold standard treatment for advanced heart failure. However, the current critical organ shortage has resulted in the ...