Steroids Limit Myocardial Edema During Ex Vivo Perfusion of Hearts Donated After Circulatory Death.

BACKGROUND: Normothermic ex vivo heart perfusion (EVHP) has been shown to improve the preservation of hearts donated after circulatory arrest and to facilitate clinical successful transplantation. Steroids are added to the perfusate solution in current clinical EVHP protocols; however, the impact of this approach on donor heart preservation has not been previously investigated. We sought to determine the impact of steroids on the inflammatory response and development of myocardial edema during EVHP. METHODS: Thirteen pigs were anesthetized, mechanical ventilation was discontinued, and a hypoxemic cardiac arrest ensued. A 15-minute warm-ischemic standoff period was observed, and then hearts were resuscitated with a cardioplegic solution. Donor hearts were then perfused ex vivo in a normothermic beating state for 6 hours with 500 mg of methylprednisolone (steroid: n = 5) or without (control: n = 8). RESULTS: The addition of steroids to the perfusate solution reduced the generation of proinflammatory cytokines (interleukin-6, -8, -1ß, and tumor necrosis factor-α) and the development of myocardial edema during EVHP (percentage of weight gain: control = 26% ± 7% versus steroid = 16% ± 10%, p = 0.049). Electron microscopy suggested less endothelial cell edema in the steroid group (injury score: control = 1.8 ± 0.2 versus steroid = 1.2 ± 0.2, p = 0.06), whereas perfusate troponin-I (control = 11.9 ± 1.9 ng/mL versus steroid = 9.5 ± 2.4 ng/mL, p = 0.448) and myocardial function were comparable between the groups. CONCLUSIONS: The addition of methylprednisolone to the perfusion solution minimizes the generation of proinflammatory cytokines and development of myocardial edema during normothermic ex vivo perfusion of hearts donated after circulatory arrest.

The Safety and Efficacy of Single-Operator Cholangioscopy in the Treatment of Difficult Common Bile Duct Stones after Failed Conventional ERCP.

BACKGROUND: Common bile duct (CBD) stones are extracted with a basket or balloon during ERCP with sphincterotomy. However, some stones are difficult to extract by conventional means. Cholangioscopy with lithotripsy is a modality to treat these difficult stones. We describe the clinical efficacy of single-operator per oral cholangioscopy (SOPOC) for difficult stones and discuss cost savings by avoiding surgical intervention. METHODS: Retrospective chart review was performed for all patients referred for difficult CBD stones. Clinical success was defined as clearing the duct of all stones. The cost of cholangioscopy (in $CDN) was calculated by adding all costs associated with the procedure(s), surgery, hospital stay or treatment of adverse events. This cost was compared with the projected cost of surgical bile duct exploration. RESULTS: A total of 51 patients (35 female) with a mean age of 66 years underwent 58 SOPOC procedures. Median procedure time was 67 minutes (95% CI, 61.5-73.5). The CBD was successfully cleared in 47 of 51 patients (93%). Minor adverse events were seen in seven patients (14%). The actual average per procedure cost was $4555±$2647. This compares with a projected cost of $7766 and $6175 for open and laparoscopic bile duct exploration, with a cost-per-case saving of $3210 and $1619, respectively. CONCLUSION: SOPOC with lithotripsy is highly effective and safe for the treatment of difficult common bile duct stones. In addition, significant cost savings may be realized by avoiding surgical bile duct exploration.