OPTIMISING THE QUALITY OF DONOR ORGANS FOR TRANSPLANTATION: STUDIES OF HORMONE RESUSCITATION OF THE BRAIN-DEAD MULTI-ORGAN DONOR AND THE DEVELOPMENT OF A LONG-TERM PRESERVATION STRATEGY TO OPTIMISE FUNCTION OF THE TRANSPLANTED HEART IN A PORCINE MODEL By Alfred J. Hing, BSc(med)(hons), MB BS Supervisor: Professor Peter S. Macdonald A thesis submitted to the University of New South Wales in fulfilment of the requirements for the degree of Doctor of Philosophy Transplant Program The Victor Chang Cardiac Research Institute, Darlinghurst, NSW, 2010 The Department of Heart and Lung Transplantation St. Vincent’s Hospital, Darlinghurst, NSW 2010 June, 2009 ORIGINALITY STATEMENT ‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no material previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project’s design and conception or in style, presentation and linguistic expression is acknowledged.’ Alfred J. Hing BSc(med)(hons), MB BS June, 2009 ii COPYRIGHT STATEMENT ‘I hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International. I have either used no substantial portions of copyright material in my thesis or I have obtained permission to use copyright material; where permission has not been granted I have applied/will apply for a partial restriction of the digital copy of my thesis or dissertation.’ Alfred Hing April, 2010 AUTHENTICITY STATEMENT ‘I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has occurred and if there are any minor variations in formatting, they are the result of the conversion to digital format.’ Alfred Hing April, 2010 iii “It was an unforgettable sight. We had taken the old heart and we needed to move damn fast to fill that huge hole with a new heart. No wonder they were frightened of us then. No wonder they thought we were out of our minds.” Adrian Kantrowitz, Detroit Michigan, October 2003 “Brilliant as the technique of the surgeons and the skill of the anaesthetists may already be, advanced as the knowledge of the immunologists may be, we feel sure they would agree with the suggestion that the current work is, relatively speaking, crude fumbling. Everybody is still learning. Everybody’s experience is still worth communicating” Anonymous (1969). The Medical Journal of Australia, 1(13):691 “Nothing can take the place of a well supported and well planned research effort for solving the most difficult of medical problems.” Daniel diBardino (1999). The History and Development of Cardiac Transplantation. Texas Heart Institute Journal, 26(3): 198-205 “…. how can you mend a broken heart ….” Barry Gibb, Robin Gibb (c. 1970) iv Dedication To my parents, Winsome (Wan Sat) Hing (1936- 1995) and Robert Joe Hing (1919-2006) This thesis and the work that it embodies is dedicated to my mother, Winsome Hing, and to my father, Robert Hing, who was ill throughout the period of my PhD research and who passed away during the preparation of this thesis. It is to both my parents that I owe so much, including my interest in science and thirst for knowledge, reasoning and wisdom. It is also due to them that I have become the person that I am today. I am where I am today because of their support, love and encouragement, and because of their willingness to allow me to discover things for myself, to choose what I wanted to do in life and to fully support me in those endeavours. v ACKNOWLEDGEMENTS There are many people to whom I am very grateful for their assistance throughout the course of this project. First and foremost, my sincere thanks and appreciation goes to my supervisor, Professor Peter Macdonald, for giving me the opportunity to undertake this project in his laboratory. His advice, support, guidance, and encouragement throughout this project were invaluable and very much appreciated. He has helped me to develop the skills and gain the experience on my journey to becoming a clinician scientist. The experiments carried out in this thesis were dependant on many people, without whom the research that underlies this thesis would not have been possible, and to whom I am very grateful. Staff from The Victor Chang Cardiac Research Institute, St. Vincent’s Hospital and the Collaborative Transplant Research Group at Sydney University who were involved at various times in the project included: Dr Mark Hicks, Dr Ling Gao, Ms Sarah Garlick, Mr Steve Faddy, Dr Aisling McMahon, Mr Scott Kesteven, Dr Graham Stewart, Mr Peter Tran, Dr Jerome Laurence, Mr Jair Kwan, Mr Andrew Dinale and Mr Jonathan Cropper. My thanks also go to Dr Michael Wilson for teaching me the skills of porcine heart transplantation, and for his assistance and advice. Later in the project, Dr Paul Jansz provided assistance and advice in the transplant study, and I am also grateful to him for his support and for arranging the leave from my job as the senior cardiothoracic surgical registrar at St. Vincent’s Hospital for me to complete this thesis. I am grateful to Dr Alasdair Watson for performing the porcine transplants in the GTN group of animals for the study described in Chapter 5. My predecessor in the laboratory, Dr Jon Ryan was a great source of advice and help, particularly in the early days of the project and I am especially grateful for the time he spent in helping me to establish myself in the project, and for teaching me about the intricacies of the Preload Recruitable Stroke Work relationship (PRSW) and multiple linear regression analysis. Professor Michael Feneley was also a great source of assistance in reviewing and discussing ventricular contractility data, and for helping me to develop a better understanding of the PRSW. Mr Scott Kesteven, whom I shared an office with throughout my research, was a great source of technical expertise, advice vi and discussion, and I am grateful for his assistance during my candidature. Dr Mark Hicks was also a great source of technical expertise, assistance and discussion. The studies reported in this thesis were funded by the National Health and Medical Research Council (NHMRC), and scholarship funding was provided by the NHMRC, the Royal Australasian College of Surgeons and the Cardiac Society of Australia and New Zealand. I would also like to acknowledge the institutional support provided by The Victor Chang Cardiac Research Institute and St. Vincent’s Hospital. Valuable assistance was provided by the Biological Resources Centre at the University of NSW in supplying animals for this study and by St. Vincent’s Pathology (SydPath), St. Vincent’s Hospital for the blood and urine assays in Chapter 4. I would also like to acknowledge the Department of Clinical Perfusion, the Department of Anaesthetics and the operating theatres at St. Vincent’s Hospital for providing some of the equipment for the experiments in this thesis. I would also like to take this opportunity to acknowledge and thank my professional mentors. In particular, I would like to thank the late Dr Mark Shanahan for his friendship, advice and encouragement for over 20 years. He, along with the late Dr Victor Chang, supported me and ignited my interest in cardiothoracic surgery and heart transplantation. I would also like to acknowledge the support of Dr Phil Spratt for the St. Vincent’s cardiothoracic surgeon-scientist program and for his support of my training in cardiothoracic surgery. I would also like to thank Dr Alan Farnsworth for his patronage and support of my training in cardiothoracic surgery. My personal thanks and gratitude go to Dr Aisling McMahon for her support, friendship, advice, assistance and encouragement, both professionally and personally. She has also provided invaluable assistance in the preparation and proofreading of this thesis, and in my development as a scientist. Finally to my parents, the late Winsome and Robert Hing, I wish to express my most heartfelt thanks and gratitude for their many years of self-sacrifice, support, caring, encouragement and understanding. vii TABLE OF CONTENTS Originality Statement .....................................................................................................ii Copyright Statement and Authenticity Statement......................................................iii Quotes..............................................................................................................................iv Dedication ........................................................................................................................v Acknowledgements.........................................................................................................vi