Cryopreservation of the common carotid artery of the rabbit: Optimization of dimethyl sulfoxide concentration and cooling rate.

This paper describes the continuation of studies that demonstrated the suitability of CP-Tes solution as a medium for the introduction and removal of dimethyl sulfoxide in rabbit common carotid arteries and established the kinetics of cryoprotectant permeation in that tissue. In this paper we report the tolerance of rabbit common carotid artery to dimethyl sulfoxide, in concentrations up to 30% (w/w), using a technique of exposure that was designed to control osmotic stress. The maximum concentration achieved without damage was 15% (w/w). Vessels were then equilibrated with 15% dimethyl sulfoxide and cooled to -80 °C at 0.22, 0.69, 2.15, or 9.63 °C/min: they were then transferred to the gas phase of a liquid nitrogen refrigerator {temperature below -160 °C) for storage. Thawing was carried out in a 37 °C water bath. The optimum rate of cooling for these conditions was found to be 0.69 °C/min. The maximal recovery of contractile force in response to 10-6 M norepinephrine was 30-40%; relaxation to acetylcholine (an endothelium-mediated function) was 80% of control, and an estimated 71% of endothelial cells survived with minimal ultrastructural change.

Residual antibiotics in allograft heart valve tissue samples following antibiotic disinfection.

Antibiotics are routinely used for the decontamination of allograft heart valves. To monitor the efficacy of this process, samples of tissue are sent for microbiological analysis. This investigation was undertaken to determine residual antibiotic concentrations in decontaminated tissue and to assess the likely inhibitory effect on microbiological cultures. After a typical decontamination protocol, both gentamicin and vancomycin were present in all tissue samples and the majority of enrichment broths at concentrations sufficient to inhibit most bacteria. The data presented indicate that protocols used by heart valve banks and associated microbiology laboratories should be reviewed, and support the use of predecontamination cultures to identify particularly virulent micro-organisms.

Processing of ovine cardiac valve allografts: 1. Effects of preservation method on structure and mechanical properties.

It is essential to have some method of preservation of allograft valves during the time between procurement and implantation. Cryopreservation is the most commonly-used storage method today but it has the major disadvantage of high cost, and because its aim is to preserve living cells only relatively gentle antimicrobial treatments are used. This study addresses two interrelated questions: Is it necessary to maintain living donor cells in the tissue graft? Can more effective measures be used to reduce the risk of transmission of diseases, especially viral diseases, via human tissue grafts. In this paper, we report an investigation of four preservation methods that could be combined with more effective disinfection: cryopreservation with dimethyl sulphoxide, storage at approximately 4 degrees C in a high concentration of glycerol as used for the preservation of skin, snap-freezing by immersion in liquid nitrogen and vitrification. Snap freezing was mechanically damaging and vitrification proved to be impracticable but two methods, cryopreservation and storage in 85% glycerol, were judged worthy of further study. Cryopreservation was shown to maintain cellular viability and excellent microscopic structure with unchanged mechanical properties. The glycerol-preserved valves did not contain any living cells but the connective tissue matrix and mechanical properties were well preserved. The importance of living cells in allograft valves is uncertain. If living cells are unimportant then either method could be combined with more effective disinfection methods: in that case the simplicity and economy of the glycerol method would be advantageous. These questions are addressed in the two later papers in this series.

Processing of cardiac valve allografts: 2. Effects of antimicrobial treatment on sterility, structure and mechanical properties.

This is the second in a series of papers that report experiments to investigate the properties required for effective tissue valve implants. This paper is concerned with investigations into alternative antimicrobial treatments and the effect these treatments produce on the structural and biomechanical properties of ovine aortic valves. Six treatments were studied: heat, peracetic acid (at two concentrations), chlorine dioxide, a surfactant cleaning agent and a solvent/detergent treatment. Samples of myocardial tissue were exposed to a mixed bacterial culture or one of three virus cultures and then decontaminated. Two of the six treatments (0.35% peracetic acid and heat) were effective in removing both bacterial and viral contamination, reducing levels of contamination by 2.5 to 3 logs, whilst a third (chlorine dioxide) was effective against viruses ( approximately 3 log reduction). Valves subjected to these treatments were examined by microscopy and measurements of mechanical properties were made. All three treatments seriously damaged endothelial cells and leaflet fibroblasts. Heat treatment also damaged connective tissue components (collagen and elastin) but these changes were not seen after chemical treatment. Mechanical testing confirmed severe damage following heat treatment but chemical treatment showed only minor effects on the elasticity of the leaflets and none on extensibility. These minor effects could be mitigated by exposure to a lower dose of peracetic acid and this treatment could be safely combined with cryopreservation or storage in 85% glycerol. Peracetic acid was the preferred disinfection method for use in the subsequent in vivo studies in sheep.

Processing of ovine cardiac valve allografts: 3. Implantation following antimicrobial treatment and preservation.

It is known that a satisfactory clinical outcome can follow the implantation of cardiac valve allografts in spite of the loss of living cells in the tissue. If viable cells are not required for long term graft function, then effective disinfection of the tissue might become possible. In an earlier paper in this series we reported that peracetic acid (PAA) is an effective antimicrobial agent for the treatment of valve allografts; it was lethal to the cells but at a concentration of 0.21% had little effect on the mechanical properties or extracellular morphology of the valve leaflets. It was also found that PAA-treatment could be combined with storage in 85% glycerol at 4 degrees C, or cryopreservation with 10% Me(2)SO, without substantial further impairment of microscopic structure or mechanical properties. In this paper we describe the implantation of processed ovine aortic valves in the descending thoracic aorta of sheep. The experimental groups included control untreated valves and valves that had been treated with antibiotics or PAA and either cryopreserved, or stored in 85% glycerol. The recipient sheep showed good clinical appearances until the experiment was terminated at six months. The explanted grafts were examined by standard morphological and mechanical testing methods. The PAA-treated valves were clearly recognisable as valves: the leaflets had fair to medium morphology in both the unpreserved and the cryopreserved groups. All leaflets had a superficial overgrowth of cells. Microsatellite analysis for allelic differences were performed on samples of donor and recipient tissues using three markers of tissue source. Only one valve, which had been treated with PAA, revealed allelic differences between donor and recipient. It is suggested that DNA-fragments may have remained after the destruction of donor cells and six months of implantation: the overgrowing cells were almost certainly of recipient origin. We conclude that our experiments, in which PAA-treatment was combined with preservation, are sufficiently encouraging to justify further studies to refine the technique, but in our opinion they are not sufficient to justify a clinical trial at this time.

Atrial transplantation for recurrent cardiac sarcoma.

Cardiac transplantation for sarcomas has met with little success and the surgical treatment remains controversial. We describe the case of a 56-year-old woman who was referred for transplantation after two procedures in which undifferentiated atrial sarcoma was locally excised successfully. The patient underwent atrial homograft transplantation, the first reported to date. Advantages of the procedure include wide atrial resection and no need for immune suppression.

Amniotic membrane grafts, "fresh" or frozen? A clinical and in vitro comparison.

BACKGROUND/AIMS: The use of "fresh" (hypothermically stored) and frozen amniotic membrane (AM) was compared in a patient with cicatricial pemphigoid with stem cell failure. The viability of both "fresh" and frozen AM epithelial cells was assessed after storage. METHODS: AM was stored at either +4 degrees C ("fresh") or at -80 degrees C (frozen). A "fresh" graft was applied to the cornea following superficial keratectomy. Subsequently, a further frozen graft was applied to the same eye. Viability of the stored AM epithelium was assessed by investigating membrane integrity and mitochondrial activity. RESULTS: In both cases the cornea re-epithelialised and visual acuity improved. Improvement, however, was not sustained. CONCLUSION: Although both procedures led to an improvement in visual acuity, "fresh" tissue performed no better than frozen in promoting re-epithelialisation. The authors suggest that logistical, safety, and cost considerations outweigh any benefits of using "fresh" as opposed to frozen graft material.

Do doctors know best? Comments on a failed trial.

A randomised controlled trial was planned to compare two different treatment strategies--structured problem solving and selective serotonin reuptake inhibitor (SSRI) medication--for patients with mild to moderate major depression. The trial was to be conducted in the primary care setting with all treatment given by general practitioners. When no patients had been recruited into the study after six months, we performed an audit of all patients with depressive symptoms attending the doctors' practices over three weeks. Exclusion criteria were changed to ease entry into the trial, but still no patients were recruited over the following six months. What went wrong?

Factors affecting the yield of cardiac valve allografts from living unrelated donors.

OBJECTIVE: Allografts are the valve of choice for fertile women, patients with infective endocarditis and those with small aortic roots. However, the supply of valves is problematic and widespread usage is restricted by limited availability. Allograft valves are available from cadaveric donors and from the explanted hearts of transplant recipients. Potentially, hearts from these patients could be an excellent source of usable aortic and pulmonary valves. However, little information is available on the suitability of such donors, the procurement rate of allograft valves from this source, or the factors that limit the yield of implantable valves from explanted hearts. METHOD: In order to examine some of these issues, we have carried out a retrospective study on the explanted hearts offered to the East Anglian Tissue Bank by Papworth hospital. Papworth hospital carries out approximately 90 heart and heart/lung transplants per year. Over a 2 year period, the tissue bank was offered 72 hearts from this programme. RESULTS: Of the 72 hearts offered, 58 were accepted for subsequent dissection and further examination. A total of 14 hearts were refused. The main reasons for refusal were extensive cardiectomy trauma (4 hearts) and abnormal valve morphology (four hearts). Of the 116 valves from those hearts accepted for dissection, 55 valves were rejected upon further examination. Reasons for rejection included: cardiectomy trauma (26 valves), abnormal morphology (22 valves), procurement/dissection trauma (7 valves). Of the 61 valves banked, four were subsequently rejected due to positive or incomplete microbiology. Procurement trauma fell to 0% in the last 12 months of the study but cardiectomy trauma remained constant and was related to previous cardiac surgery. Overall, the yield of implantable valves was 0.8 valves/donor. However, the yield showed considerable variation, from 1.0 valves/donor for donors diagnosed as cardiomyopathy to 0.5 valves/donor for donors with ischaemic heart disease who had undergone previous cardiac surgery. CONCLUSION: It is possible to predict the likely yield of explanted heart valves from different groups of heart transplant recipients, based on diagnosis and previous history. The yield of usable valves could be increased by avoidance of injury, both during cardiectomy and subsequent removal of the valves; this is achievable through appropriate training.

Cryopreservation of the common carotid artery of the rabbit: optimization of dimethyl sulfoxide concentration and cooling rate.

This paper describes the continuation of studies that demonstrated the suitability of CP-Tes solution as a medium for the introduction and removal of dimethyl sulfoxide in rabbit common carotid arteries and established the kinetics of cryoprotectant permeation in that tissue. In this paper we report the tolerance of rabbit common carotid artery to dimethyl sulfoxide, in concentrations up to 30% (w/w), using a technique of exposure that was designed to control osmotic stress. The maximum concentration achieved without damage was 15% (w/w). Vessels were then equilibrated with 15% dimethyl sulfoxide and cooled to -80 degrees C at 0.22, 0.69, 2.15, or 9.63 degrees C/min: they were then transferred to the gas phase of a liquid nitrogen refrigerator (temperature below -160 degrees C) for storage. Thawing was carried out in a 37 degrees C water bath. The optimum rate of cooling for these conditions was found to be 0.69 degrees C/min. The maximal recovery of contractile force in response to 10(-6) M norepinephrine was 30-40%; relaxation to acetylcholine (an endothelium-mediated function) was 80% of control, and an estimated 71% of endothelial cells survived with minimal ultrastructural change.

Fractures in cryopreserved arteries.

The common carotid artery of the rabbit, a typical small elastic artery, can be cryopreserved using dimethyl sulfoxide, slow cooling, storage at less than -160 degrees C, and rapid warming. This technique provides satisfactory preservation of muscle and endothelial cells, but in about 75% of cases, gross circumferential fractures occur in the vessel wall. This paper investigates the influence of vehicle solution composition, cryoprotectant concentration, cooling rate, and storage temperature on the occurrence of cracks. When cooling was halted at -80 degrees C and the arteries were stored at this temperature, fractures no longer occurred. Possible mechanisms are discussed and it is proposed that mechanical stresses develop in the vitreous material that separates the ice crystals and lead to structural failure.

Cryopreservation of the common carotid artery of the rabbit.

We describe experiments on the cryopreservation of the rabbit common carotid artery aimed at improving upon previous results. We describe the design of a double clamp which holds the artery during transportation and storage, preventing twisting, shortening, and collapse of the vessel. The device allowed perfusion with solutions as desired and markedly reduced the extent of endothelial loss during procurement and processing. We also studied the effects of three vehicle solutions; a modified Hanks' solution, a solution originally developed for the cryopreservation of smooth muscle (K-Pipes), and a solution designed for corneal endothelium (CP-Tes). The criteria used to make the assessments were smooth muscle contractility and the structure and function of the vascular endothelium. A new staining method for vascular endothelium (combining propidium iodide with silver nitrate) is described. We found that there was significantly more endothelial cell damage in rabbit carotid arteries frozen in Hanks' solution than in the other solutions, and the recovery of smooth muscle contractility was lowest in the Hanks' group. Arteries cryopreserved using CP-Tes as the vehicle solution showed less endothelial cell damage than arteries preserved with either K-Pipes or Hanks' solution, and these arteries also exhibited the greatest relaxation response to acetylcholine. We conclude that careful handling of the vessels is important; of the solutions studied, CP-Tes is preferred for the cryopreservation of rabbit carotid artery with Me2SO.

The possibility of resuscitating livers after warm ischemic injury.

The number of clinical liver transplants that can be performed is limited by the availability of suitable donor organs. If it were possible to harvest and use livers after cardiac arrest, the supply could be improved. The mechanisms of damage in warm ischemia are not yet well understood and the consequences of transplanting a liver that is unable to provide immediate life-support are unacceptable. This study aims to identify areas for more detailed study in an attempt to improve the quality of livers harvested after significant warm ischemia, and to select acceptable organs for transplantation. Porcine livers were subjected to 75 min of warm ischemia and then perfused at 37 degrees C for 3 hr, during which period biochemical monitoring was carried out. At the end of the perfusion, histological and transmission electron microscopical studies were made. Large amounts of the intracellular enzymes ALT, AST, and LDH were released into the perfusate during the first 30 min of perfusion, but this--and the further amounts released during the subsequent 2.5 hr--was influenced by the composition of the perfusate. The inclusion of the substrates fructose and oleate, plus amino acids, substantially reduced this release and also improved the ability of the livers to metabolize ammonia. Oxygen free-radical scavengers had a significant, but smaller, beneficial effect. Electron microscopy confirmed the value of perfusion in improving cell morphology, and the additional value of including metabolic substrates. This study shows that hepatocellular structure and function can be improved by appropriate perfusion methods that also provide a simple means of monitoring some important functions. Both metabolic support and neutralization of oxygen free-radical action have a role to play in this approach to rendering ischemically injured livers acceptable for clinical use.

The effect of polyvinylpyrrolidone and the cooling rate during corneal cryopreservation.

The effect upon endothelial cell survival of (a) PVP and (b) the cooling rate was investigated during the cryopreservation of rabbit corneas with 3 mol/liter dimethyl sulfoxide (Me2SO) dissolved in a hyperkalemic buffer vehicle solution that we designated CPTES; this solution was designed specifically to restrict deleterious ionic imbalances and cell swelling during hypothermic procedures. Polyvinylpyrrolidone (PVP) was used as the colloid and the corneas were cooled at 0.03, 0.1, 1, 25, or 125 degrees C/min, using the minimum amount of extracellular solution. Electron microscopy as well as staining with fluorescein diacetate and ethidium bromide (FDA/EB) was used to assess cellular integrity. To reduce osmotic stress, steps for the serial equilibration of the cryoprotectant additives (CPAs) were based upon calculations that predict endothelial volume during CPA exchange. A toxicity study showed that at 0 degrees C all the CPA equilibration protocols were well tolerated; for example, FDA/EB staining indicated that 97% intact cells were retained following direct transfer to 3 mol/liter Me2SO in CPTES to which 40% w/v PVP had been added as an osmotic buffer. However, less than 20% of cells were intact by FDA/EB staining with all corneas frozen at rates > 1 degree C/min regardless of which equilibration protocol was employed, nor were there any intact cells when 3 mol/liter Me2SO in CPTES was used alone at the lowest cooling rate. At intermediate cooling rates viability was improved: the highest mean survival of 81% was obtained using 3 mol/liter Me2SO in CPTES plus 40% PVP. Electron microscopy showed that detachment of the endothelial layer often occurred, but least damage was evident following exposure to 3 mol/liter Me2SO in CPTES plus 40% PVP and cooling at 1 degree C/min. No thawed cornea could maintain normal control of hydration immediately upon return to isotonic medium. The results show that, with these cryopreservation protocols, loss of cell integrity occurs at cooling rates greater than 1 degree C/min, whereas at lower rates higher survival of individual cells was achieved, but cellular adhesion to the basement membrane was impaired.

Effects of cooling rate and glycerol concentration on the structure of the frozen kidney: assessment by cryo-scanning electron microscopy.

An experimental technique, employing a directional solidification stage for controlled freezing of tissue samples and low-temperature scanning electron microscopy for observation of the structure of the frozen-hydrated samples, was used to study freezing processes in the kidney. Parametric studies in which the cooling rate during freezing and the concentration of glycerol in the tissue were varied confirmed the results of earlier freeze-substitution studies. The results suggest a mechanism for ice propagation in the kidney similar to that already proposed for the liver, in which ice originates in, and is subsequently propagated through, the peritubular vasculature. The ice front dehydrates the cells and tubular structures encountered in its path, thus preventing intraluminal freezing. At higher rates of cooling and increased concentrations of glycerol there is less dehydration of cortical structure and intraluminal freezing occurs.

Some effects of propane-1,2-diol on human platelets.

The Kedem-Katchalsky equations and permeability data previously reported (F. G. Arnaud and D. E. Pegg. Permeation of glycerol and propane-1,2-diol into human platelets. Cryobiology 27, 130-136, 1990) have been used to design methods for adding and removing propane-1,2-diol (propylene glycol, PG) with human platelets. Mean platelet volume was kept within the tolerated range of 60 to 120% of normal. PG concentrations of 0.5, 1.0, 2.0, 2.5, and 3.0 M were studied at 2, 21, and 37 degrees C. PG was removed only at 21 degrees C. The effects of concentration of PG, temperature, and duration of exposure on the hypotonic stress response and ADP-induced aggregation were measured. It was found that platelets would tolerate exposure to PG concentrations up to 2 M at 21 or 2 degrees C for up to 15 min. The extent of damage increased considerably at higher temperatures and concentrations. These data provide the necessary basis for experiments to cryopreserve platelets with PG.

Hypothermic preservation of corneas in a hyperkalaemic solution (CPTES): II. Extended storage in the presence of chondroitin sulphate.

Periods of preservation for donor corneas, even for short times, are necessary to facilitate optimum conditions in penetrating keratoplasty. However, current techniques for corneal storage at low temperatures may not provide optimal conditions for maintaining tissue integrity. In particular, the ionic composition of the storage medium has received little attention since it has been assumed throughout that the normal complement of ions in tissue culture media will also be suitable for preservation at reduced temperatures. This study extends our previous investigations on the merits of using CPTES (corneal-potassium-TES), a potassium-rich balanced salt solution containing an impermeant anionic pH buffer (TES), as a storage solution specifically designed to prevent the loss of intracellular potassium and minimise endothelial cell swelling during the time that the normal regulatory processes are switched off. The effect of adding the natural polymer chondroitin sulphate (CS) as a colloid osmotic agent to the hyperkalaemic storage medium is now examined. Corneas stored in CPTES containing 2.5% chondroitin sulphate retained a very high level of structural and functional integrity after three, five, and seven days storage at 0 degrees C; furthermore, stromal swelling was restricted to only 21%. All corneas stored in CPTES + 2.5% CS showed active endothelial function by thinning efficiently at rates that were greater than those previously reported for rabbit corneas stored for similar lengths of time in either M-K medium or K-sol. The zwitterionic buffers TES and HEPES were interchangeable in the hyperkalaemic solution and were non-toxic to corneal endothelium at a concentration of 100 mM. These compounds offer excellent pH buffering in bicarbonate-free medium.

Hypothermic preservation of corneas in a hyperkalaemic solution (CPTES): I. Short-term storage in the absence of colloid osmotic agents.

Preservation solutions for short-term storage of isolated donor corneas for use in penetrating keratoplasty have all been based on tissue culture medium, on the assumption that media designed to maintain the viability of cells at physiological temperatures will also provide suitable conditions for preservation at reduced temperatures. But for hypothermic preservation of some other tissues and organs, when ionic pumps are inhibited, it is unnecessary to support metabolism, and beneficial control of ion and water distribution between intra- and extracellular compartments is achieved by storage in appropriately formulated 'intracellular-type' solutions. We have therefore designed a solution that will restrict ionic imbalances and minimise endothelial cell swelling in corneas during exposure at reduced temperatures. This potassium-rich solution contains the biological pH buffer TES as an impermeant anion and is designated CPTES (corneal-potassium-TES). The structural and functional integrity of rabbit corneas stored at 0 degrees C in CPTES, without the addition of colloid osmotic agents, is compared with that of corneas stored in glutathione bicarbonate Ringers' solution (GBR), an 'extracellular-type' medium formulated for the maintenance of endothelial integrity during in-vitro perfusion at 34 degrees C. Corneas swelled significantly less during storage in CPTES than in GBR and could be stored for five days before reaching the same degree of hydration as corneas stored for only three days in GBR. Gross structural integrity and endothelial ultrastructure were maintained during storage for three and five days in CPTES. The rate of thinning of corneas stored in CPTES was significantly greater than in comparable groups of corneas stored in GBR. However, the efficient dehydration of corneas stored in CPTES was always preceded during perfusion by a brief period of additional swelling which was shown to be an osmotic response during the elution of the buffer compound TES that had permeated the stroma during storage. The omission of calcium or the addition of adenosine and glutathione to the CPTES preservation medium had no detectable effect on the integrity of the endothelium, but the omission of bicarbonate was beneficial, producing significantly higher rates of stromal thinning during normothermic perfusion. Additional benefits for extending storage by including colloid osmotic agents are described in a companion paper.

The mechanism of action of retrograde oxygen persufflation in renal preservation.

Vascular perfusion of gaseous oxygen has been used to prolong the in vitro survival of a number of isolated organs, and has been shown to improve the hypothermic preservation of ischemically injured kidneys that were subsequently transplanted. We have investigated the mechanism of this effect. Rabbit kidneys were subjected to 60 min of warm ischemia prior to preservation for 24 hr with Ross, Marshall, and Escott's hypertonic citrate solution, with or without retrograde oxygen persufflation (ROP) via the renal vein. It was found that adenine nucleotide levels were almost doubled in the ROP-preserved kidneys, principally due to higher adenosine triphosphate (ATP) concentrations. It was shown that cytochrome oxidase activity was unaffected by ischemia or preservation method, but studies with the metabolic inhibitors ouabain and a mixture of cyanide and iodoacetate suggested that ATP was being synthesized during the storage period but was also being utilized to power the active volume-regulating pump. Morphological examination revealed a much greater degree of cell swelling and cytological injury in the kidneys not subject to ROP, and the interstitial space appeared much reduced in the latter group. At the ultrastructural level, the ROP-treated kidneys showed generally well-preserved mitochondria, mostly in the energized "orthodox" configuration. In contrast, the mitochondria in the nonpersufflated kidneys were generally in the "condensed" deenergized state. We conclude that the provision of sufficient oxygen by ROP allows the continued production of ATP in sufficient quantities to permit improved maintenance of cellular volume and morphology under the conditions of low-temperature storage that we have studied.