Surfactant Improves Graft Function After Gastric Acid–Induced Lung Damage in Lung Transplantation Ilhan Inci, MD, Sven Hillinger, MD, Stephan Arni, PhD,

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Surfactant Improves Graft Function After Gastric Acid–Induced Lung Damage in Lung Transplantation Ilhan Inci, MD, Sven Hillinger, MD, Stephan Arni, PhD, Wolfgang Jungraithmayr, MD, Demet Inci, MD, Peter Vogt, MD, Boris Leskosek, Gesine Hansen, MD, Walter Weder, MD The Annals of Thoracic Surgery Volume 95, Issue 3, Pages 1013-1019 (March 2013) DOI: 10.1016/j.athoracsur.2012.10.027 Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Schematic presentation of the study. (BAL = bronchoalveolar lavage; Tx = treatment.) The Annals of Thoracic Surgery 2013 95, 1013-1019DOI: (10.1016/j.athoracsur.2012.10.027) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Analysis of variance for repeated measures, which consists of all measurements made during the reperfusion period for oxygenation, significantly differed (p = 0.001) between the surfactant group (SURF [solid line] and the control group (CON [broken line]). Oxygenation: partial arterial oxygen pressure/fraction of inspired oxygen (PaO2/FiO2 ratio). Timepoints: baseline (BL); 10 minutes before occlusion of the right lung (BO); 1 hour after occlusion of the right side (T1); 2 hours after occlusion of the right side (T2); 3 hours after occlusion of the right side (T3); 4 hours after occlusion of the right side (T4); 5 hours after occlusion of the right side (T5); and 6 hours after occlusion of the right side (T6). The Annals of Thoracic Surgery 2013 95, 1013-1019DOI: (10.1016/j.athoracsur.2012.10.027) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Bronchoalveolar lavage (BAL) neutrophil count at the end of experiment (BAL3) was significantly higher (p = 0.03) in the control group (CON [gray bars]) compared with the surfactant-treated group (SURF [black bars]). BAL1 = 24 hours after acid injury before retrieval at the end of 24 hours of ventilation (left lung); BAL2 = right lung without injury before retrieval at the end of 24 hours of ventilation; and BAL3 = transplanted left lung, at the end of experiment. The Annals of Thoracic Surgery 2013 95, 1013-1019DOI: (10.1016/j.athoracsur.2012.10.027) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Bronchoalveolar lavage (BAL) interleukin (IL)-6 levels. A significantly lower IL-6 level was observed in the surfactant group (SURF) compared with the control group (CON) in BAL3 (p = 0.03). BAL1 = 24 hours after acid injury before retrieval at the end of 24 hours of ventilation (all left lungs from 2 groups, n = 12]); BAL2 = right lung without injury before retrieval at the end of 24 hours of ventilation (all right lungs from both groups, n = 12); and BAL3 = transplanted left lung, at the end of experiment (SURF, n = 6; CON, n = 4). The Annals of Thoracic Surgery 2013 95, 1013-1019DOI: (10.1016/j.athoracsur.2012.10.027) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Serum interleukin (IL)-8 level was higher in the control group (CON) compared with the surfactant group (SURF) at 3 hours (T3 [gray bars]) and 6 hours (T6 [black bars]) after left lung dependent reperfusion (p = 0.03). (Open bars = baseline.) The Annals of Thoracic Surgery 2013 95, 1013-1019DOI: (10.1016/j.athoracsur.2012.10.027) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Myeloperoxidase activity in lung tissue at the end of experiment was significantly higher (p = 0.03) in the control group (CON) compared with the surfactant group (SURF). The Annals of Thoracic Surgery 2013 95, 1013-1019DOI: (10.1016/j.athoracsur.2012.10.027) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Minimal surface tension in bronchoalveolar lavage (BAL). BAL1 = 24 hours after acid injury before retrieval at the end of 24 hours of ventilation (left lung) (all left lungs from 2 groups, n = 12); BAL2 = right lung without injury before retrieval at the end of 24 hours of ventilation (all right lungs from both groups, n = 12); and BAL3 = transplanted left lung, at the end of experiment (surfactant group [SURF], n = 6; control group [CON], n = 4). BAL3 SURF versus BAL3 CON, p = 0.03. The Annals of Thoracic Surgery 2013 95, 1013-1019DOI: (10.1016/j.athoracsur.2012.10.027) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 (A) The surfactant group showed relatively normal structure with reduced cellular infiltration. (B) The control group showed alveolar congestion, hemorrhage, and neutrophil and macrophage infiltration. The Annals of Thoracic Surgery 2013 95, 1013-1019DOI: (10.1016/j.athoracsur.2012.10.027) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions