Please see accompanying Prescribing Information.

© 2015 Essential Pharmaceuticals, LLC ESS 2015-1 01/15

• REFERENCES •1) S.-Y. Sung, C.-Y Lin, J.-Y. Song et al., Myocardial protection

in donor heart preservation: A comparison between Bretschneider’s histidine-trytophan-ketogluterate solution and cold blood Cardioplegia. Transplant Proceedings, 2014 46, 1077-1081

2) KreshJY,etal.TherelativebufferingpowerofCardioplegiasolutions.TheJournalofThoracicandCardiovascularSurgery1987 Feb. 43 (2) 309-11

3) M.Garlicki,J.Kolcz,etal.,MyocardialProtectionforTransplantation. Transplantation Proceedings 1999, 31, 2079-2083

4) K.GU,S.Kinetal.,HTKSolutionismoreeffectivethanUWsolutionforcardiacpreservation.TransplantationProceedings,1996 Vol 28 1906-1907

5) S. Lee, C-S Huang, et al., Histidine-tryptophan-ketogluterate or Celsior:Whichismoresuitableforcoldpreservationforcardiacgraftsfromolderdonors?AnnThoracSurg2011;91:755-63

6) J.Ackemann,W.Gross,etal.,CelsiorvsCustodiol:earlypostischemicrecoveryafterCardioplegiaandischemiaat5°C.AnnThoracSurg2002;74:522-9

• TRULY READY TO USE •

ORGAN PRESERVATION SOLUTION

HEART

Formoreinformation,e-mailusat info@essentialpharma.comorcall1-844-Ess-Prod (377-7763)

Visit our websites at www.custodiol.com www.essentialpharma.com

Please see accompanying PrescribingInformation.

100 Princeton South Corporate Center Suite 140 Ewing, NJ 08628

Please see accompanying Prescribing Information.

© 2015 Essential Pharmaceuticals, LLC ESS 2015-1 01/15

• REFERENCES •1) S.-Y. Sung, C.-Y Lin, J.-Y. Song et al., Myocardial protection

in donor heart preservation: A comparison between Bretschneider’s histidine-trytophan-ketogluterate solution and cold blood Cardioplegia. Transplant Proceedings, 2014 46, 1077-1081

2) KreshJY,etal.TherelativebufferingpowerofCardioplegiasolutions.TheJournalofThoracicandCardiovascularSurgery1987 Feb. 43 (2) 309-11

3) M.Garlicki,J.Kolcz,etal.,MyocardialProtectionforTransplantation. Transplantation Proceedings 1999, 31, 2079-2083

4) K.GU,S.Kinetal.,HTKSolutionismoreeffectivethanUWsolutionforcardiacpreservation.TransplantationProceedings,1996 Vol 28 1906-1907

5) S. Lee, C-S Huang, et al., Histidine-tryptophan-ketogluterate or Celsior:Whichismoresuitableforcoldpreservationforcardiacgraftsfromolderdonors?AnnThoracSurg2011;91:755-63

6) J.Ackemann,W.Gross,etal.,CelsiorvsCustodiol:earlypostischemicrecoveryafterCardioplegiaandischemiaat5°C.AnnThoracSurg2002;74:522-9

• TRULY READY TO USE •

ORGAN PRESERVATION SOLUTION

HEART

Formoreinformation,e-mailusat info@essentialpharma.comorcall1-844-Ess-Prod (377-7763)

Visit our websites at www.custodiol.com www.essentialpharma.com

Please see accompanying PrescribingInformation.

100 Princeton South Corporate Center Suite 140 Ewing, NJ 08628

INTRODUCTIONCUSTODIOL® HTK SOLUTION

Custodiol ® HTK Solution is intended forperfusionandflushingofheart(anddonor liver, kidney, pancreas) prior to removalfromthedonorforpreserving

these organs during hypothermic storage and transport totherecipient.Itisbasedontheprincipalofinactivatingorganfunctionbywithdrawalofextracellularsodiumandcalcium,togetherwithintensebufferingoftheextracellularspacebymeansofhistidine/histidineHCI,soastoprolongtheperiodforwhichtheorganswilltolerateinterruptionofbloodandoxygen.

• SingleDoseofBretschneider’sHTKsolutioncouldeffectivelyreducepumpingtimeandaffordsimilarmyocardial protection compared with repeated dosesofCBCinthepreservationofdonated hearts(1)

• Containslowerconcentrationsofsodiumandcalcium and induces cardiac arrest by deprivation ofextra-cellularsodiumforactionpotential (1)

• Ketogluterate provides high energy production via adenosinetriphosphateduringreperfusionandtryptophan stabilizes cell membranes

• Manitolactsinosmoticregulationofthecellmembrane

• ThemajoradvantagesofHTKsolutionarederivedfromhistidine,whichactsasabuffer,enhancingtheefficiencyofanaerobicglycolysis.Kreshetal.foundthatahistidineprotein-typebuffersolutionwassuperior to bicarbonate-based and tromethamine-based hyperkalmic crystalloid cardioplegic solutions forstabilizingintracellularpHandpostoperativebiochemical and mechanical data(2)

A COMPARISON IN DONOR HEART PRESERVATION: A COMPARISON BETWEEN BRETSCHNEIDER’S HISTIDINE-TRYPTOPHANE-KETOGLUTERATE SOLUTION AND COLD BLOOD CARDIOPLEGIA

ThisstudyaimedtocomparetheefficacyofmyocardialprotectionusingsingledoseofBretschneider’shistidine-tryptophan-ketogluterate (HTK) solution and repeateddosesofcoldbloodcardioplegia(CBC)indonorheartpreservationforhearttransplant.(1)

TheauthorsconcludedthatasingledoseofHTKsolutionorrepeateddosesofCBCsolutionaffordsimilarmyocardialprotectioninthepreservationofdonated hearts.(1)

Multivariateanalysisshowthesignificantreducedpumping time in HTK group (P = .002)

Clinical Variable HTK (n = 16) STH (n = 45) P Value_____________________________________________________________________________________________________Inotropic score at 19.4 ± 15.5 7.1 ± 6.3 <.001 24 h postoperatively_____________________________________________________________________________________________________Pumping Time (min) 158.3 ± 32.0 173.9 ± 33.2 .002_____________________________________________________________________________________________________LIVEF (%) at 7 d 62.0 ± 4.4 60.7 ± 7.3 .806 Postoperatively_____________________________________________________________________________________________________Age (y) 50.7 ± 11.5 50.6 ± 12.5 .648

_____________________________________________________________________________________________________

MultivariateAnalysisofSurvivingPatientsData are shown as mean ± standard deviation.

Abbreviations:LVEF,leftventricularejectionfraction;HTK,histidinetryptophanketoglutaratesolution;STH,StThomas’Hospitalsolution

HEARTMYOCARDIAL PROTECTION FOR TRANSPLANTATION(3)

The present study is a randomized clinical trial assessing preservation

ofthedonorheartusingthreecommonCardioplegicsolutions. (Table 1)(3)

Based on collected results it seems obvious that all threesolutionsareinthesamerangeofeffectivenessinregard to myocardial protection.(3)

HTK SOLUTION COMPARED TO UW FOR CARDIAC TRANSPLANTATION(4)

ThepurposeofthisstudywastoaccesstheefficacyofHTKsolutionascomparedwithUWsolutioninexperimentalheartpreservation.(4)

Thistableshowstherecoveryofhemodynamicdataontheheartfor8and12hoursofpreservation.Following8hoursofpreservationtherecoveryofAF,CF,CO,SPandRPPinHTKgroup(2)wssignificantlyincreasedcompared with that in group 1 (P<.05).(4)

In our study, histologic changes in the zero biopsies analysisofdonordata,totalischemictime,reperfusiontime, mortality rate, and hemodynamic parameters indicated that HTK cardioplegia is more optimal in our conditions.(3)

WefoundabetterrecoveryofcardiacfunctionandlowerleakageofCPKintheheartsstoredinHTKsolutioncomparedwiththoseinUWsolutionfollowing8hoursofstorage.(4)

TheefficacyofHTKSolutionisattributedtothehighbufferingcapacityprovidedbythehistidine,whichsuppresses ischemia-induced acidosis and sustains a cytosolicATOlevel.

Inconclusion,HTKsolutionismuchmoreeffectivethanUWsolutionforheartpreservation.HTKmayleadtobettertechniquesofheartpreservationfortransplantation.(4)

Mortality Mortality Mortality Summary 2 days 14 days 90 days _____________________________________________________________Solution n % n % n % n %_____________________________________________________________Celsior 1 4.0 3 11 4 14 4 14HTK 6 5.0 17 12 17 12 17 12UW 3 4.0 9 13 11 16 11 17

Table 1. Composition ofUW,HTKand Celsior

Solutions

Substrates (mmol/L) UW HTK Celsior _____________________________________________Lactobionate 100 - 80Raffinose 30 - -NA+ 30 15 -K+ 125 10 -MG++ 5 4 -CI- - 50 -H2P04- 25 - -SO4- 5 - -Adenosine 5 - -Allopurinal 1 - -Glutathione 3 - 3Insulin 100 - -Dexamethasone 8 - -HES 50 - -Bactrimml/L 0.5 - -Osmolarity 320 310 320PH(Ost.C) 7.4 7.2 7.3Mannitol - 30 60Glutamate - - 20CaCl2 - 0.015 0.245NAOH - - 100KCl - 9 15MgCl2 - 4 13Histidine - 198 30Tryptophan - 2 -Ketogluturate - 1 -

Mortality in the 224 Recipients

Cardiac Functional Recovery (%)mean=SE*,<.05vs.Group1#,<.05vsGroup3CO;cardiacoutput,AF;aorticflow,CF;

coronaryflow;RPPratepressureproduct

Time_____________________________________________________________Group (h) CO AF CF RPP_____________________________________________________________1.UW(n=7) 8 49.7±2.4 47.4±4.2 57.1±6.2 71.0±1.8_____________________________________________________________2. HTK (n = 8) 8 78.1 ± 5.9* 71.5 ± 8.6* 87.8 ± 5.8* 83.6 ± 4.4*_____________________________________________________________3.UW(n=5) 12 16.6±3.4 10.7±2.4 37.6±8.4 40.9±8.2_____________________________________________________________4. HTK (n = 5) 12 29.7 ± 1.4# 24.2 ± 2.5# 4.26 ± 1.5 56.7 ± 4.1

HEARTThis study compared the protective effectsoftwowidelyusedpreservationsolutions, histidine-tryptophan-ketogluterate (HTK) and Celsior (CEL) forischemia-reperfusioninjuryusing

a rat heterotopic heart transplantation model with older donors(5)

TheauthorsconcludedthatHTKexhibitssuperiorprotections during cold storage in a syngenic rat heart transplantation model compared with CEL.(5)

HTKSolutionPreservesATPLevelsinCardiacGrafts (5)

HTK-TreatedGraftshavelessmetobolicstress(5)

HH

H

100

80

60

40

20

0

Rela

tive

ATP

leve

l(%

of c

ontr

ol)

0 hr 6 hr 12 hr 18 hr

Saline

CEL

HTK

H * *

A

CEL=Celsior;CPK=creatinephosphokinase;HMGB1=high-mobilitygroupbox1;HTK=histidine-tryptophan-ketoglutarate;MDA=malondialdehyde.

aValuesaremeans±SD;p values vs CEL are shown.

TABLE 1. MYOCARDIAL DAMAGE AND LIPID PEROXIDATION

100

80

60

40

20

0

Rela

tive

ATP

leve

l(%

of c

ontr

ol)

0 hr 6 hr 12 hr 18 hr

Saline

CEL

HTKB

*

Hearts From Younger Donors (n = 5) Hearts From Older Donors (n = 5)

Markers Saline CEL HTK p Valueª Saline CEL HTK p Valueª

Serum CPK (IU/l)

Serum troponinI(pg/mL)

Serum HMGB1(ng/mL)

5,360.8 ± 1,385.8

127.3 ± 37.5

1.32 ± 0.62

2,336.6 ± 841.0

37.4 ± 18.5

1.15 ± 0.55

1,946.1 ± 837.1

40.6 ± 20.1

1.15 ± 0.21

0.402

0.312

0.462

9,594.8 ± 1,526.7

304.1 ± 9.1

3.17 ± 1.79

8,094.1 ± 673.0

184.8 ± 33.0

2.33 ± 0.52

4,620.3 ± 441.4a

141.7 ± 36.5a

0.98 ± 0.75a

0.048

0.0184

0.0258

Tissue MDA (umol/mgtotal protein)

1.38 ± 0.43 1.11 ± 0.14 1.00 ± 0.42 0.15 2.57 ± 0.84 1.34 ± 0.18 0.8 ± 0.13 0.0014

Of myocardial damage

Of oxidative damage

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

CELSIOR VS CUSTODIOL TheaimofthisexperimentalstudywastocomparetheprotectiveefficacyofthecardioplegicsolutionsCelsiorand Custodiol. Canine hearts were

examinedwithregardtoenergymetabolismandearlypost-ischemicrecoveryafter8or12hoursofischemiaat5°C.(6)

The authors concluded that, in the canine heart, Celsior showed no advantage over Cardioplegia with Custodiol. Differenceswereobservedhowever,whichmaybeclinicallyimportantespeciallyinthecaseoflongstoragetimes.

TABLE 2. MYOCARDIAL ENERGY METABOLISM DURING ISCHEMIA

8HoursIschemiaat5°CTherewasnosignificantdifferenceinmyocardialATPcontentbetweenpreservationsolutionsafter8hours.After12hours,heartsoftheCustodiolgroupcontainedsignificantlymoreATPcompared with Celsior-treated hearts (p<0.05).TheATP/ADPratiowassignificantlyhigherinCustodiol-treatedheartsafterbothischemictimes.(p < 0.01, 12 hours p < 0.05)(6)

12HoursIschemiaat5°CHeartswereperfusedwithCustodiolorCelsiorandstoredat5°Cfor8or12hours.Valuesaremeans±SEMoffiveexperiments(givenasµmol/gdryweight).ªSignificantlydifferentfromcorrespondingischemictimeoftheCustodiolgroup;p<0.05.ᵇSignificantlydifferentfromcorrespondingischemictimeoftheCustodiolgroup;p<0.01.ADP=adenosinediphosphate;AMP=adenosinemonophosphate;ATP=adenosinetriphosphate.

Custodiol® Celsior®

Phosphocreatine

ATP

ADP

AMP

ATP/ADPratio

Lactate

Glycogen

5.1 ± 0.3

20.1 ± 0.6

6.4 ± 0.3

1.4 ± 0.1

3.2 ± 0.2

99.3 ± 3.7

142.3 ± 18.7

4.0±0.2ª

17.7 ± 1.3

7.0 ± 0.3

1.7 ± 0.1

2.5±0.1ᵇ

81.5±8.1ª

155.8 ±11.3

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Phosphocreatine

ATP

ADP

AMP

ATP/ADPratio

Lactate

Glycogen

3.2 ± 0.5

14.1 ± 1.6

6.3 ± 0.4

2.1 ± 0.3

2.3 ± 0.0

134.4 ± 6.3

111.2 ± 16.8

2.4 ± 0.5

11.3±1.0ª

6.9 ± 0.5

2.4 ± 0.2

1.6±0.1ª

116.2 ± 11.3

119.6 ± 23.8

Custodiol® Celsior®

HEART

Fold

ed F

lap

for P

I

Layo

ut P

I to

11 x

17

1/1

Blac

k (fo

lded

to 3

.4 x

5.5

)

Incidenceofarrhythmiasduringreperfusion

.........

Ventremoved

0

10

20

30

40

50

60

inci

dent

s of

am

hyth

mia

s [%

]

11 12 13 14 15 16 17 18 19 20reperfusion [min]

CEL

HTK

HeartswereperfusedwithCustodiol(—○—,—•—)orCelsior(—▼—,——)andstoredat5°Cfor8hours(—•—,—▼—ª)or12hours(—○—,——).Valuesaremeans±SEM,n=7foreachgroup.ªSignificantlydifferentfromcorrespondingischemictimeoftheCustodiolgroup;analysisofvariancep < 0.01.

Comparingtheincidenceofarrhythmiasduringthefirst20minutesofreperfu-sion, Celsior-treated hearts showed a higher rate - arrhythmic beats than Custodiol-treatedheartsafter8hoursas

wellasafter12hoursofischemia.Thedifferencewassignificantafter8hours(ANOVA,p<0.01)butnotafter12hoursofischemia.(6)

HEART

ΔΔ

Please see accompanying Prescribing Information.

© 2015 Essential Pharmaceuticals, LLC ESS 2015-1 01/15

• REFERENCES •1) S.-Y. Sung, C.-Y Lin, J.-Y. Song et al., Myocardial protection

in donor heart preservation: A comparison between Bretschneider’s histidine-trytophan-ketogluterate solution and cold blood Cardioplegia. Transplant Proceedings, 2014 46, 1077-1081

2) KreshJY,etal.TherelativebufferingpowerofCardioplegiasolutions.TheJournalofThoracicandCardiovascularSurgery1987 Feb. 43 (2) 309-11

3) M.Garlicki,J.Kolcz,etal.,MyocardialProtectionforTransplantation. Transplantation Proceedings 1999, 31, 2079-2083

4) K.GU,S.Kinetal.,HTKSolutionismoreeffectivethanUWsolutionforcardiacpreservation.TransplantationProceedings,1996 Vol 28 1906-1907

5) S. Lee, C-S Huang, et al., Histidine-tryptophan-ketogluterate or Celsior:Whichismoresuitableforcoldpreservationforcardiacgraftsfromolderdonors?AnnThoracSurg2011;91:755-63

6) J.Ackemann,W.Gross,etal.,CelsiorvsCustodiol:earlypostischemicrecoveryafterCardioplegiaandischemiaat5°C.AnnThoracSurg2002;74:522-9

• TRULY READY TO USE •

ORGAN PRESERVATION SOLUTION

HEART

Formoreinformation,e-mailusat info@essentialpharma.comorcall1-844-Ess-Prod (377-7763)

Visit our websites at www.custodiol.com www.essentialpharma.com

Please see accompanying PrescribingInformation.

100 Princeton South Corporate Center Suite 140 Ewing, NJ 08628