Impact of Reperfusion Calcium and pH on the Resuscitation of Hearts Donated After Circulatory Death Christopher White, MD, Emma Ambrose, BS, Alison Müller,

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Impact of Reperfusion Calcium and pH on the Resuscitation of Hearts Donated After Circulatory Death Christopher White, MD, Emma Ambrose, BS, Alison Müller, MS, Sanaz Hatami, MD, Yun Li, MD, Hoa Le, BS, James Thliveris, PhD, Rakesh Arora, MD, PhD, Trevor Lee, MD, Ian Dixon, PhD, Ganghong Tian, MD, PhD, Jayan Nagendran, MD, PhD, Larry Hryshko, PhD, Darren Freed, MD, PhD The Annals of Thoracic Surgery Volume 103, Issue 1, Pages 122-130 (January 2017) DOI: 10.1016/j.athoracsur.2016.05.084 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (A) Ionic changes during ischemia. Anaerobic metabolism results in the production of hydrogen ions that activate the sodium-hydrogen exchanger and cause the accumulation of sodium ions inside the myocyte. The sodium-potassium adenosine triphosphatase (ATPase) is not able to extrude the excess sodium ions and maintain the normal membrane potential because of a lack of available ATP. Consequently, as ischemia progresses, there is an accumulation of sodium and hydrogen ions inside the myocyte and depolarization of the membrane potential. (B) Ionic changes during reperfusion. Reperfusion washes out the hydrogen ions that have accumulated in the interstitial space and creates a large gradient for sodium-hydrogen exchange. The influx of sodium ions into the myocyte during early reperfusion forces the sodium-calcium exchanger to function in reverse mode and import calcium ions across the sarcolemma. Intracellular ionic homeostasis cannot be restored until the sodium-potassium ATPase is able to reestablish the resting membrane potential and normal intracellular sodium levels, which will allow the sodium-calcium exchanger to return to a forward mode of operation and extrude excess calcium from the cytoplasm. (RyR = ryanodine receptor.) The Annals of Thoracic Surgery 2017 103, 122-130DOI: (10.1016/j.athoracsur.2016.05.084) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Experimental protocol examining the impact of initial reperfusion calcium concentration (part 1) and pH (part 2) on the resuscitation of hearts donated after circulatory death. (A) Fifteen minutes after declaration of circulatory arrest, hearts were reperfused with a cardioplegic solution of varying [Ca2+] and pH and then perfused ex vivo for 1 hour before functional and metabolic assessments were carried out. (B) Experimental groups according to the [Ca2+] and pH of the cardioplegic solution delivered during the 3-minute initial reperfusion. §Hearts from the [Ca2+] 220 μmol/L group in part 1 also represented the pH 7.4 group in part 2. The Annals of Thoracic Surgery 2017 103, 122-130DOI: (10.1016/j.athoracsur.2016.05.084) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Myocardial edema during ex vivo heart perfusion: (left) part 1, [Ca2+]; (right) part 2, pH. The Annals of Thoracic Surgery 2017 103, 122-130DOI: (10.1016/j.athoracsur.2016.05.084) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Coronary vascular resistance during ex vivo heart perfusion: (left) part 1, [Ca2+]; (right) part 2, pH. The Annals of Thoracic Surgery 2017 103, 122-130DOI: (10.1016/j.athoracsur.2016.05.084) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Myocardial oxygen consumption during ex vivo heart perfusion: (left) part 1, [Ca2+]; (right) part 2, pH. The Annals of Thoracic Surgery 2017 103, 122-130DOI: (10.1016/j.athoracsur.2016.05.084) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Lactate profile during ex vivo heart perfusion: (left) part 1, [Ca2+]; (right) part 2, pH. The p values represent results of the analysis of variance for arterial lactate (black bars), venous lactate (gray bars), and the venoarterial lactate difference among the four treatment groups in part 1 and part 2. (NS = not significant.) The Annals of Thoracic Surgery 2017 103, 122-130DOI: (10.1016/j.athoracsur.2016.05.084) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Cardiac index of hearts in a working mode: (left) part 1, [Ca2+]; (right) part 2, pH. The Annals of Thoracic Surgery 2017 103, 122-130DOI: (10.1016/j.athoracsur.2016.05.084) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions