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The Journal of Extra-corporeal... Mar 2023: Cardiovascular perfusion is a dynamic healthcare profession where new practices are frequently introduced. Despite the emergence of evidence-based clinical practice...
: Cardiovascular perfusion is a dynamic healthcare profession where new practices are frequently introduced. Despite the emergence of evidence-based clinical practice guidelines, little is known about their dissemination at the institutional level. Clinical practice surveys have been used to identify current trends in perfusion practice in the areas of equipment, techniques, and staffing. This survey aims to describe clinical perfusion practices across adult cardiac surgical programs located in a large, single, geographical region of the United States. : Following Institutional Review Board (IRB) approval, an 81-question survey was distributed to 167 adult perfusion programs across the Zone IV region of the American Society of Extracorporeal Technology (AmSECT), a non-profit professional society representing the extracorporeal technology community. Surveys were distributed to chief perfusionists through the Research Electronic Data Capture (REDCap) web-based survey response system. : Responses were received from 58 of 167 centers across (34.7% response rate). Centrifugal pumps were used at 81% ( = 47) of centers and 96.6% ( = 56) use an open venous system or hard-shell venous reservoir. Del Nido was the most frequently used cardioplegia strategy with 62.1% ( = 36) of centers reporting its use. The use of electronic medical records was reported in 43% ( = 25) of centers, while 84.5% ( = 49) reported using Cardiopulmonary Bypass (CPB) protocols (>75% of all CPB activities). Extracorporeal Membrane Oxygenation (ECMO) support was reported in 93.1% ( = 54) of programs, with 59.2% of programs ( = 34) employing a perfusionist as ECMO Coordinator. The + 1 staffing model was reported by 50% ( = 29), with 24% supporting the + 1 staffing for after-hours and on-call procedures. : Clinical practice surveys can be effective tools to inform clinicians about contemporary perfusion practice and identify deviations from professional standards and guidelines. Subsequent surveys may describe trends over time, assess standardization of practice, measure adherence to evidence-based guidelines, and foster improved patient care and outcomes.
Topics: Adult; United States; Humans; Perfusion; Extracorporeal Membrane Oxygenation; Cardiac Surgical Procedures; Surveys and Questionnaires; Cardiopulmonary Bypass
PubMed: 37034099
DOI: 10.1051/ject/2023002 -
Transplantation Nov 2021The use of cold preservation solutions to rapidly flush and cool the kidney followed by static cold storage in ice has been the standard kidney preservation technique... (Review)
Review
The use of cold preservation solutions to rapidly flush and cool the kidney followed by static cold storage in ice has been the standard kidney preservation technique for the last 50 y. Nonetheless, changing donor demographics that include organs from extended criteria donors and donation after circulatory death donors have led to the adoption of more diverse techniques of preservation. Comparison of hypothermic machine perfusion and static cold storage techniques for deceased donor kidneys has long been debated and is still contested by some. The recent modification of hypothermic machine perfusion techniques with the addition of oxygen or perfusion at subnormothermic or near-normothermic temperatures are promising strategies that are emerging in clinical practice. In addition, the use of normothermic regional perfusion to resuscitate abdominal organs of donation after circulatory death donors in situ before cold flushing is also increasingly being utilized. This review provides a synopsis of the different types of preservation techniques including their mechanistic effects and the outcome of their application in clinical practice for different types of donor kidney.
Topics: Graft Survival; Kidney; Kidney Transplantation; Organ Preservation; Perfusion; Tissue Donors
PubMed: 33982904
DOI: 10.1097/TP.0000000000003679 -
The Journal of Extra-corporeal... Mar 2022A diverse and equitable working environment is desirable. In 2011, a survey was distributed to all female perfusionists in the United States. This survey suggested that...
A diverse and equitable working environment is desirable. In 2011, a survey was distributed to all female perfusionists in the United States. This survey suggested that the female perfusionists share the same difficulties as women in the labor force. The role of women in society in general is clearly changing. Female perfusionists have been part of that evolution. Promoting equality and respecting diversity are central to life today. A follow-up survey was distributed to evaluate the status and the change in gender stereotypes in the field of perfusion over the past 10 years. Women make up nearly half of the U.S. labor force and 35.7% of the present perfusion workforce in North America (1,077 certified women). Women make 82 cents for every dollar that men earn and this disparity widens for women with more education. The purpose of this survey was to poll women in perfusion to evaluate concerns and opinions in their careers and to compare to the 2011 survey results. In December 2021, a 39-question survey (surveymonkey.com, San Mateo, CA) was made available to all female perfusionists in North American via social media websites (Facebook.com, Perfusion.com, LinkedIn.com, Perflist, Perfmail, and FPP Listserv). There were 384 responses to the 2021 survey compared to the 538 responses in 2011. About 32.1% of the survey participants have been used in perfusion for more than 20 years; 37.6% have earned a master's degree compared to 2011, where 18.3% had master's level education; 72.5% are the financial providers for their family with 44.2% earning $101-150,000.00 and 40.3% greater than $200,000.00, which is a significant change from 2011; 61.5% consider themselves under moderate stress compared to 63.0% in 2011; 94.3% take call on a regular basis; and 74.1% feel they miss essential family functions because of their schedules. Similarly, 62.8% felt discriminated against because of gender compared to 50.9% in 2011. This survey suggests that the female perfusionists have shown to be assertive (72% are the primary financial supporter of their families) and competent in the field of cardiovascular perfusion (nearly 40% have masters degrees). Further analysis is needed to discern whether female perfusionists are treated with comparable respect as their male colleagues when 50.0% report some discrimination or harassment in their workplace.
Topics: Female; Male; Humans; United States; Perfusion; Workforce; Surveys and Questionnaires; Certification
PubMed: 36380828
DOI: 10.1182/ject-29-34 -
Multimedia Manual of Cardiothoracic... Apr 2023Available donor organs for lung transplantation are scarce. Ex vivo lung perfusion provides a platform to preserve, assess, and recondition donor lungs and can thereby...
Available donor organs for lung transplantation are scarce. Ex vivo lung perfusion provides a platform to preserve, assess, and recondition donor lungs and can thereby aid in enlarging the donor pool. This video tutorial discusses the indications, preparation, and surgical technique for and the initiation, maintenance and termination of the ex vivo lung perfusion procedure.
Topics: Humans; Perfusion; Lung; Extracorporeal Circulation; Lung Transplantation; Tissue Donors
PubMed: 37010027
DOI: 10.1510/mmcts.2023.011 -
The British Journal of Surgery May 2021Attempts to improve limb preservation for transplantation using ex vivo perfusion have yielded promising results. However, metabolic acidosis, aberrant perfusate...
BACKGROUND
Attempts to improve limb preservation for transplantation using ex vivo perfusion have yielded promising results. However, metabolic acidosis, aberrant perfusate biochemistry and significant perfusion-induced oedema are reported universally. Optimizing perfusion protocols is therefore essential for maintaining tissue health.
METHODS
A randomized, two-stage open preclinical trial design was used to determine the optimal temperature and mean arterial pressure for machine perfusion. Conditions compared were: normothermic machine perfusion at 70 mmHg (NMP-70); subnormothermic perfusion (28°C) at 70 mmHg; subnormothermic (28°C) perfusion at 50 mmHg; and hypothermic perfusion (10°C) at 30 mmHg. Following this, a head-to-head experiment was undertaken comparing the optimal machine perfusion with static cold storage. Paired bilateral limbs (10 in total) were randomized to either 8 h of static cold storage, or 2 h of static cold storage and 6 h of optimal machine perfusion. Both groups of limbs were then reperfused on a circuit primed with matched blood from unrelated donors for 4 h without immunosuppression.
RESULTS
NMP-70 resulted in less tissue injury and stable perfusion biochemistry. Assessing reperfusion outcomes, static cold storage resulted in acidosis with increased lactate and a worsening electrolyte profile, necessitating bolus infusions of bicarbonate to prevent graft loss. Conversely, NMP-70 was associated with haemodynamic and biochemical stability. Histologically, on reperfusion with allogeneic whole blood, limbs subjected to static cold storage exhibited multifocal ischaemic injury and increased inflammation, which was absent with NMP-70. Static cold storage also resulted in significant oedema compared with NMP-70.
CONCLUSION
Normothermic perfusion resulted in superior graft preservation and less reperfusion injury compared with the current static cold storage protocol.
Topics: Animals; Blood Pressure; Composite Tissue Allografts; Graft Survival; Models, Animal; Perfusion; Random Allocation; Reperfusion Injury; Specimen Handling; Swine; Temperature
PubMed: 34043778
DOI: 10.1002/bjs.11921 -
EBioMedicine Dec 2023Normothermic regional perfusion (NRP) and hypothermic-oxygenated-perfusion (HOPE), were both shown to improve outcomes after liver transplantation from donors after...
BACKGROUND
Normothermic regional perfusion (NRP) and hypothermic-oxygenated-perfusion (HOPE), were both shown to improve outcomes after liver transplantation from donors after circulatory death (DCD). Comparative clinical and mechanistical studies are however lacking.
METHODS
A rodent model of NRP and HOPE, both in the donor, was developed. Following asystolic donor warm ischemia time (DWIT), the abdominal compartment was perfused either with a donor-blood-based-perfusate at 37 °C (NRP) or with oxygenated Belzer-MPS at 10 °C (donor-HOPE) for 2 h. Livers were then procured and underwent 5 h static cold storage (CS), followed by transplantation. Un-perfused and HOPE-treated DCD-livers (after CS) and healthy livers (DBD) with direct implantation after NRP served as controls. Endpoints included the entire spectrum of ischemia-reperfusion-injury.
FINDINGS
Healthy control livers (DBD) showed minimal signs of inflammation during 2 h NRP and achieved 100% posttransplant recipient survival. In contrast, DCD livers with 30 and 60 min DWIT suffered from greater mitochondrial injury and inflammation as measured by increased perfusate Lactate, FMN- and HMGB-1-levels with subsequent Toll-like-receptor activation during NRP. In contrast, donor-HOPE (instead of NRP) led to significantly less mitochondrial-complex-I-injury and inflammation. Results after donor-HOPE were comparable to ex-situ HOPE after CS. Most DCD-liver recipients survived when treated with one HOPE-technique (86%), compared to only 40% after NRP (p = 0.0053). Following a reduction of DWIT (15 min), DCD liver recipients achieved comparable survivals with NRP (80%).
INTERPRETATION
High-risk DCD livers benefit more from HOPE-treatment, either immediately in the donor or after cold storage. Comparative prospective clinical studies are required to translate the results.
FUNDING
Funding was provided by the Swiss National Science Foundation (grant no: 32003B-140776/1, 3200B-153012/1, 320030-189055/1, and 31IC30-166909) and supported by University Careggi (grant no 32003B-140776/1) and the OTT (grant No.: DRGT641/2019, cod.prog. 19CT03) and the Max Planck Society. Work in the A.G. laboratory was partially supported by the NIH R01NS112381 and R21NS125466 grants.
Topics: Animals; Humans; Liver Transplantation; Rodentia; Prospective Studies; Perfusion; Graft Survival; Organ Preservation; Liver; Tissue Donors; Inflammation
PubMed: 37924707
DOI: 10.1016/j.ebiom.2023.104861 -
American Journal of Transplantation :... May 2022Pancreas transplantation improves and extends the life of patients with insulin-dependent diabetes. Pancreata from extended criteria donors have been increasingly used...
Pancreas transplantation improves and extends the life of patients with insulin-dependent diabetes. Pancreata from extended criteria donors have been increasingly used due to the scarcity of available grafts. Normothermic ex situ pancreas perfusion (NESPP) can keep grafts metabolically active, potentially allowing for assessment and organ repair, and could improve outcomes of marginal grafts. A novel NESPP technique was developed and tested. Porcine pancreata were removed after a short period of warm ischemia and subjected to 6 h of NESPP. Perfusion parameters, potential graft assessment markers and graft injury were measured. Next, pancreata subjected to 3 h of NESPP were transplanted and animals were followed for up to 3 days. Graft function and injury post-transplantation were evaluated. Using this novel system of perfusion, pancreata were perfused for an extended period of time with minimal edema. Histology at the end of perfusion showed intact islet cells with only mild signs of tissue injury. NESPP transplanted grafts showed immediate function after transplantation, with glucose levels in normal range. NESPP maintains a physiologic environment and excellent graft function without causing significant graft injury. Porcine pancreas transplantation is feasible and allows for in vivo graft assessment of pancreas function and injury after NESPP.
Topics: Animals; Humans; Organ Preservation; Pancreas; Pancreas Transplantation; Perfusion; Swine; Warm Ischemia
PubMed: 35258859
DOI: 10.1111/ajt.17019 -
Liver Transplantation : Official... Dec 2017The efficacy of cold in situ perfusion and static storage of the liver is a possible determinant of transplantation outcomes. The aim of this study was to determine... (Meta-Analysis)
Meta-Analysis Review
The efficacy of cold in situ perfusion and static storage of the liver is a possible determinant of transplantation outcomes. The aim of this study was to determine whether there is evidence to substantiate a preference for a particular perfusion route (aortic or dual) or perfusion/preservation solution in donation after brain death (DBD) liver transplantation. The Embase, MEDLINE, and Cochrane databases were used (1980-2017). Random effects modeling was used to estimate effects on transplantation outcomes based on (1) aortic or dual in situ perfusion and (2) the use of University of Wisconsin (UW), histidine tryptophan ketoglutarate (HTK), Celsior, and/or Institut Georges Lopez-1 (IGL-1) solutions for perfusion/preservation. A total of 22 articles were included (2294 liver transplants). The quality of evidence ranged from very low to moderate Grading of Recommendations, Assessment, Development and Evaluations score. Meta-analyses were conducted for 14 eligible studies. Although there was no difference in the primary nonfunction (PNF) rate, a higher peak alanine aminotransferase (ALT) was recorded in dual compared with aortic-only UW-perfused livers (standardized mean difference, 0.24; 95% confidence interval, 0.01-0.47); a back-table portal venous flush was undertaken in the majority of aortic-only perfused livers. There were no relevant differences in peak enzymes, PNF, thrombotic graft loss, biliary complications, or 1-year graft survival in comparisons between dual-perfused livers using UW, HTK, Celsior, or IGL-1. In conclusion, there is no significant evidence that aortic-only perfusion of the DBD liver compromises transplantation outcomes, and it may be favored because of its simplicity. However, there is currently insufficient evidence to advocate for the use of any particular perfusion/preservation fluid over the others. Liver Transplantation 23 1615-1627 2017 AASLD.
Topics: Allografts; Cold Ischemia; Graft Survival; Humans; Liver; Liver Transplantation; Organ Preservation; Organ Preservation Solutions; Perfusion; Practice Guidelines as Topic; Tissue and Organ Procurement; Treatment Outcome
PubMed: 28734125
DOI: 10.1002/lt.24829 -
Experimental Eye Research Jul 2022The key risk factor for glaucoma is elevation of intraocular pressure (IOP) and alleviating it is the only effective therapeutic approach to inhibit further vision loss....
The key risk factor for glaucoma is elevation of intraocular pressure (IOP) and alleviating it is the only effective therapeutic approach to inhibit further vision loss. IOP is regulated by the flow of aqueous humour across resistive tissues, and a reduction in outflow facility, is responsible for the IOP elevation in glaucoma. Measurement of outflow facility is therefore important when investigating the pathophysiology of glaucoma and testing candidate treatments for lowering IOP. Due to similar anatomy and response to pharmacological treatments, mouse eyes are a common model of human aqueous humour dynamics. The ex vivo preparation, in which an enucleated mouse eye is mounted in a temperature controlled bath and cannulated, has been well characterised and is widely used. The postmortem in situ model, in which the eyes are perfused within the cadaver, has received relatively little attention. In this study, we investigate the postmortem in situ model using the iPerfusion system, with a particular focus on i) the presence or absence of pressure-independent flow, ii) the effect of evaporation on measured flow rates and iii) the magnitude and pressure dependence of outflow facility and how these properties are affected by postmortem changes. Measurements immediately after cannulation and following multi-pressure facility measurement demonstrated negligible pressure-independent flow in postmortem eyes, in contrast to assumptions made in previous studies. Using a humidity chamber, we investigated whether the humidity of the surrounding air would influence measured flow rates. We found that at room levels of humidity, evaporation of saline droplets on the eye resulted in artefactual flow rates with a magnitude comparable to outflow, which were eliminated by a high relative humidity (>85%) environment. Average postmortem outflow facility was ∼4 nl/min/mmHg, similar to values observed ex vivo, irrespective of whether a postmortem delay was introduced prior to cannulation. The intra-animal variability of measured outflow facility values was also reduced relative to previous ex vivo data. The pressure-dependence of outflow facility was reduced in the postmortem relative to ex vivo model, and practically eliminated when eyes were cannulated >40 min after euthanisation. Overall, our results indicate that the moderately increased technical complexity associated with postmortem perfusion provides reduced variability and reduced pressure-dependence in outflow facility, when experimental conditions are properly controlled.
Topics: Animals; Aqueous Humor; Glaucoma; Intraocular Pressure; Mice; Perfusion; Tonometry, Ocular; Trabecular Meshwork
PubMed: 35525299
DOI: 10.1016/j.exer.2022.109103 -
Frontiers in Immunology 2023In response to the increasing demand for lung transplantation, lung perfusion (EVLP) has extended the number of suitable donor lungs by rehabilitating marginal organs....
In response to the increasing demand for lung transplantation, lung perfusion (EVLP) has extended the number of suitable donor lungs by rehabilitating marginal organs. However despite an expanding use in clinical practice, the responses of the different lung cell types to EVLP are not known. In order to advance our mechanistic understanding and establish a refine tool for improvement of EVLP, we conducted a pioneer study involving single cell RNA-seq on human lungs declined for transplantation. Functional enrichment analyses were performed upon integration of data sets generated at 4 h (clinical duration) and 10 h (prolonged duration) from two human lungs processed to EVLP. Pathways related to inflammation were predicted activated in epithelial and blood endothelial cells, in monocyte-derived macrophages and temporally at 4 h in alveolar macrophages. Pathways related to cytoskeleton signaling/organization were predicted reduced in most cell types mainly at 10 h. We identified a division of labor between cell types for the selected expression of cytokine and chemokine genes that varied according to time. Immune cells including CD4 and CD8 T cells, NK cells, mast cells and conventional dendritic cells displayed gene expression patterns indicating blunted activation, already at 4 h in several instances and further more at 10 h. Therefore despite inducing inflammatory responses, EVLP appears to dampen the activation of major lung immune cell types, what may be beneficial to the outcome of transplantation. Our results also support that therapeutics approaches aiming at reducing inflammation upon EVLP should target both the alveolar and vascular compartments.
Topics: Humans; Perfusion; CD8-Positive T-Lymphocytes; Endothelial Cells; Lung Transplantation; Lung; Inflammation
PubMed: 37465668
DOI: 10.3389/fimmu.2023.1142228