lung transplantation pediatric recipients ishlt 2007 j heart lung transplant 2007;26
TRANSCRIPT
LUNG TRANSPLANTATION
Pediatric Recipients
ISHLT 2007J Heart Lung Transplant 2007;26
RECIPIENT AGE DISTRIBUTION FOR PEDIATRIC LUNG RECIPIENTS - NUMBER
(Transplants: January 1986 - June 2006)
050
100150200250300350400450500550600650700750
1986-1995 (N=303) 1996-6/2006 (N=752)
Nu
mb
er
of
Tra
nsp
lan
ts
<1 1-5 6-11 12-17
ISHLT 2007J Heart Lung Transplant 2007;26
RECIPIENT AGE DISTRIBUTION FOR PEDIATRIC LUNG RECIPIENTS - PERCENTAGE
(Transplants: January 1986 - June 2006)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1986-1995 (N=303) 1996-6/2006 (N=752)
% o
f T
ran
sp
lan
ts
12-17
6-11
1-5
<1
ISHLT 2007J Heart Lung Transplant 2007;26
DONOR TYPE DISTRIBUTION BY YEAR OF TRANSPLANT FOR PEDIATRIC LUNG RECIPIENTS
(Transplants: 1986-2005)
0
10
20
30
40
50
60
70
80
90
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Transplant Year
Nu
mb
er
of
Tra
nsp
lan
ts
LivingDeceased
ISHLT 2007NOTE: This figure includes only the lung transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as evidence that the number of lung transplants worldwide has declined in recent years.J Heart Lung Transplant 2007;26
DONOR TYPE DISTRIBUTION BY RECIPIENT AGE GROUP WITHIN ERA FOR PEDIATRIC LUNG RECIPIENTS (Transplants: January 1986 - June 2006)
0
50
100
150
200
250
300
350
400
450
500
0-5 years 6-11 years 12-17 years 0-5 years 6-11 years 12-17 years
Recipient Age (Years)
Nu
mb
er
of T
ran
sp
lan
ts
LivingDeceased
1986-1995 1996-6/2006
ISHLT 2007J Heart Lung Transplant 2007;26
AGE DISTRIBUTION FOR DONORS OF PEDIATRIC
LUNG RECIPIENTS (Transplants: January 1986 - June 2006)
485
178
168
146
39
2
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Donor Age (Years)
Nu
mb
er o
f T
ran
spla
nts
60+
50-59
35-49
18-34
12-17
0-11
ISHLT 2007J Heart Lung Transplant 2007;26
AGE DISTRIBUTION OF PEDIATRIC LUNG RECIPIENTS
By Year of Transplant
0
20
40
60
80
10012-17 Years1-11 Years
<1 Year
Nu
mb
er o
f T
ran
spla
nts
1 3 4 6
20
4751
4643
8272
84 85
67 6659
6671
ISHLT 2007
70
77
J Heart Lung Transplant 2007;26
NUMBER OF CENTERS REPORTING PEDIATRIC LUNG TRANSPLANTS
0
10
20
30
40
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Transplant Year
Nu
mb
er o
f C
ente
rs R
epo
rtin
g
Ped
iatr
ic T
ran
spla
nts
ISHLT 2007 J Heart Lung Transplant 2007;26
NUMBER OF CENTERS REPORTING PEDIATRIC LUNG TRANSPLANTS BY CENTER VOLUME
0
10
20
30
40
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Transplant Year
Nu
mb
er o
f C
ente
rs R
epo
rtin
g
Ped
iatr
ic T
ran
spla
nts
20+ transplants
10-19 transplants
5-9 transplants
1-4 transplants
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG TRANSPLANTATION: Indications (Transplants: January 1991 – June 2006)
DIAGNOSIS AGE: < 1 Year
AGE: 1-5 Years
AGE: 6-11 Years
AGE: 12-17 Years
Cystic Fibrosis 3 3.7% 107 54.9% 441 69.%
Primary Pulmonary Hypertension 10 16.1% 18 22.2% 23 11.8% 53 8.3%
Re-Transplant: Obliterative Bronchiolitis 6 7.4% 8 4.1% 22 3.4%
Congenital Heart Disease 19 30.6% 8 9.9% 2 1.0% 5 0.8%
Idiopathic Pulmonary Fibrosis 7 8.6% 6 3.1% 23 3.6%
Obliterative Bronchiolitis (Not Re-TX) 5 6.2% 9 4.6% 21 3.3%
Re-Transplant: Not OB 3 4.8% 1 1.2% 7 3.6% 16 2.5%
Interstitial Pneumonitis 6 9.7% 11 13.6% 1 0.5% 5 0.8%
Pulmonary Vascular Disease 7 11.3% 4 4.9% 6 3.1% 1 0.2%
Eisenmenger’s Syndrome 1 1.6% 5 6.2% 5 2.6% 6 0.9%
Pulmonary Fibrosis, Other 1 1.6% 1 1.2% 4 2.1% 11 1.7%
Surfactant Protein B Deficiency 9 14.5% 2 2.5%
COPD/Emphysema 1 1.2% 2 1.0% 5 0.8%
Bronchopulmonary Dysplasia 1 1.6% 2 2.5% 6 3.1%
Bronchiectasis 3 1.5% 4 0.6%
Other 5 8.1% 7 8.6% 6 3.1% 26 4.1%
ISHLT 2007 J Heart Lung Transplant 2007;26
DIAGNOSIS IN PEDIATRIC LUNG RECIPIENTSBY YEAR OF TRANSPLANT
Age: 12-17 Years
0
25
50
75
100
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
% o
f T
ran
spla
nts
PPH Cystic Fibrosis
ISHLT 2007 J Heart Lung Transplant 2007;26
0%
20%
40%
60%
80%
100%
Europe (N=82) North America (N=338) Other (N=24)
% o
f T
ran
sp
lan
ts
0-5 years 6-11 years 12-17 years
PEDIATRIC LUNG TRANSPLANTS:AGE DISTRIBUTION BY LOCATION Transplants between January 2000 and June 2006
ISHLT 2007 J Heart Lung Transplant 2007;26
0%
20%
40%
60%
80%
100%
Europe (N=79) North America (N=328) Other (N=23)
% o
f T
ran
sp
lan
ts-
Cystic Fibrosis PPH IPF OB Other Congenital heart disease Re-TX
PEDIATRIC LUNG TRANSPLANTS:DIAGNOSIS DISTRIBUTION BY LOCATION
Transplants between January 2000 and June 2006
ISHLT 2007
NOTE: Unknown diagnoses were excluded from this tabulation.
Total number of transplants reported:Europe = 82North America = 338Other = 24J Heart Lung Transplant 2007;26
0%
20%
40%
60%
80%
100%
Europe (N=82) North America (N=327) Other (N=23)
% o
f Do
no
rs
0-5 6-11 12-17 18-34 35-49 50-59 60+
PEDIATRIC LUNG TRANSPLANTS:DONOR AGE DISTRIBUTION BY LOCATION
Transplants between January 2000 and June 2006
ISHLT 2007
NOTE: Transplants with unknown donor age were excluded from this tabulation.
Total number of transplants reported:Europe = 82North America = 338Other = 24J Heart Lung Transplant 2007;26
LUNG TRANSPLANTATIONKaplan-Meier Survival by Age Group
(Transplants: January 1990 - June 2005)
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13Years
Su
rviv
al (
%)
Adult (N=20,275)
Pediatric (N=965)
HALF-LIFE Adult = 4.8 Years; Pediatric = 4.3 Years
P = 0.7878
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG TRANSPLANTATIONKaplan-Meier Survival by Procedure Type
(Transplants: January 1990 - June 2005)
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11Years
Su
rviv
al (
%)
Single Lung (N=80)
Bilateral/Double Lung (N=792)
HALF-LIFE Single Lung: 2.2 Years; Bilateral/double Lung: 4.6 Years
P < .0001
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG TRANSPLANTATIONKaplan-Meier Survival for Congenital Diagnoses (Transplants: January 1990 – June 2005)
0
25
50
75
100
0 1 2 3 4 5Years
Su
rviv
al (
%)
Eisenmenger's Syndrome (N=15)
Other Congenital Heart Disease (N=34)
Eisenmenger's + Other Congenital Heart Disease (N=49)
N at risk = 8
N at risk = 9
N at risk = 11
ISHLT 2007
Eisenmenger’s vs. Other: p = 0.19
J Heart Lung Transplant 2007;26
PEDIATRIC LUNG TRANSPLANTATIONKaplan-Meier Survival by Age Group
(Transplants: January 1990 - June 2005)
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12
Years
Su
rviv
al (
%)
<1 Year (N=58)
1-11 Years (N=268)
12-17 Years (N=546)
<1 year vs. 1-11 years: p = .6597<1 year vs. 12-17 years: p = 0.11751-11 years vs. 12-17 years: p = .0122
HALF-LIFE<1 Year: 6.4 Years1-11 Years: 5.7 Years12-17 Years: 4.0 Years
N at risk = 5
N at risk = 9
N at risk = 8
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG TRANSPLANTATIONConditional Kaplan-Meier Survival by Age Group
(Transplants: January 1990 - June 2005)
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12
Years
Su
rviv
al (%
)
<1 Year (N=37)1-11 Years (N=183)
12-17 Years (N=353)
<1 year vs. 1-11 year: p = .5737<1 year vs. 12-17 years: p = .06861-11 years vs. 12-17 years: p = .0279
N at risk = 5
N at risk = 9
N at risk = 8
CONDITIONAL HALF-LIFE<1 Year: 8.8 Years1-11 Years: 10.5 Years12-17 Years: 5.8 Years
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG TRANSPLANTATION Kaplan-Meier Survival by Era (Transplants: January 1988 - June 2005)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Years
Su
rviv
al (
%)
1988-1994 (N=217)
1995-6/2005 (N=758)
HALF-LIFEUnconditional 1988-1994: 2.6 Years; 1995-6/2005: 4.5 YearsConditional 1988-1994: 7.1 Years; 1995-6/2005: 7.2 Years
P-value for 88-94 vs. 95-6/05: 0.0563
N at risk = 18
N at risk = 11
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG TRANSPLANTATIONKaplan-Meier Survival by Donor Type for Recipients Age 11-17 Years
(Transplants: January 1990 - June 2005)
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10
Years
Su
rviv
al (
%)
Deceased Donor (N = 546)
Living Donor (N = 72)
p = 0.9149
N at risk = 8
N at risk = 19
HALF-LIFEDeceased: 4.0 YearsLiving: 3.8 Years
ISHLT 2007 J Heart Lung Transplant 2007;26
0
2
4
6
8
10
12
14
16
18
0-<1 month 1-<12 months 12-<36 months 36+ months Not reported
Nu
mb
er o
f R
e-T
ran
spla
nts
PEDIATRIC LUNG RE-TRANSPLANTS Between January 1994 and June 2006
ISHLT 2007
Time Between Previous and Current Transplant
J Heart Lung Transplant 2007;26
0
10
20
30
40
50
60
70
80
90
100
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Years
Su
rviv
al (
%)
N=5 at risk at 5 years
PEDIATRIC LUNG RETRANSPLANTSSurvival for Transplants Performed Between January 1994 and June 2005
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG RECIPIENTS Functional Status of Surviving Recipients
(Follow-ups: April 1994-June 2006)
0%
20%
40%
60%
80%
100%
1 Year (N = 361) 3 Years (N = 239) 5 Years (N = 142) 7 Years (N=65)
No Activity Limitations Performs with Assistance Total Assistance
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG RECIPIENTS Rehospitalization Post-transplant of Surviving Recipients
(Follow-ups: April 1994 - June 2006)
0%
20%
40%
60%
80%
100%
Up to 1 Year (N =491)
Between 2 and 3Years (N = 303)
Between 4 and 5Years (N = 184)
Between 6 and 7Years (N = 91)
No Hospitalization Hospitalized, Not Rejection/Not InfectionHospitalized, Rejection Hospitalized, Infection OnlyHospitalized, Rejection + Infection
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG RECIPIENTS Rehospitalization Post-transplant of Surviving Recipients
(Follow-ups: April 1994 - June 2006)
0%
20%
40%
60%
80%
100%
Up to 1 Year (N =491)
Between 1 and 3Years (N =270)
Between 3 and 5Years (N = 166)
Between 5 and 7Years (N = 84)
No Hospitalization Hospitalized, Not Rejection/Not InfectionHospitalized, Rejection Hospitalized, Infection OnlyHospitalized, Rejection + Infection
ISHLT 2007 J Heart Lung Transplant 2007;26
0
10
20
30
40
50
60
Any Induction (N = 155) Polyclonal ALG/ATG (N = 46) IL2R-antagonist (N = 108)
% o
f p
atien
tsPEDIATRIC LUNG RECIPIENTS
Induction ImmunosuppressionFor transplants between January 2001 and June 2006
ISHLT 2007 J Heart Lung Transplant 2007;26
0
10
20
30
40
50
60
70
Any Induction Polyclonal ALG/ATG IL2R-antagonist
% o
f p
ati
en
ts
2001 2002
2003 2004
2005 1/2006-6/2006
PEDIATRIC LUNG RECIPIENTSInduction Immunosuppression (Transplants: January 2001 - June 2006)
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG TRANSPLANTATION
Kaplan-Meier Survival Stratified by Induction Use (Transplants: January 2001 - June 2005)
0
25
50
75
100
0 1 2 3 4
Years
Su
rviv
al (
%)
Induction (N = 114)
No Induction (N = 104)
p = 0.9324
ISHLT 2007 J Heart Lung Transplant 2007;26
0
20
40
60
80
100
Cyclosporine Tacrolimus Rapamycin MMF Azathioprine Prednisone
% o
f P
atie
nts
Year 1 (N = 210) Year 5 (N = 112)
PEDIATRIC LUNG RECIPIENTS Maintenance Immunosuppression at Time of Follow-up
(Follow-ups: January 2001 and June 2006)
NOTE: Different patients are analyzed in Year 1 and Year 5
ISHLT 2007 J Heart Lung Transplant 2007;26
0
20
40
60
80
100
CalcineurinInhibitor
CellCycle Prednisone CalcineurinInhibitor
CellCycle Prednisone
% o
f P
ati
en
ts
CyA
TacTac
CyAAZA
AZA
MMFMMF
PEDIATRIC LUNG RECIPIENTS Maintenance Immunosuppression at Time of Follow-up
(Follow-ups: January 2001 and June 2006)
1 Year Follow-up (N = 210) 5 Year Follow-up (N = 112)NOTE: Different patients are analyzed in Year 1 and Year 5
ISHLT 2007
NOTE: 5% of patients were on both calcineurin inhibitors at different point during the year; these patients are not counted in either group. In the 5-year tabulations, 14% were reported to be on both drugs during the year.J Heart Lung Transplant 2007;26
0%
20%
40%
60%
80%
100%
Year 1 (N = 210) Year 5 (N = 112)
% o
f P
ati
en
ts
Other
Tacrolimus + MMF
Tacrolimus + AZA
Cyclosporine + MMF
Cyclosporine + AZA
PEDIATRIC LUNG RECIPIENTS Maintenance Immunosuppression Drug Combinations at Time of Follow-up Report
(Follow-ups: January 2001 and June 2006)
NOTE: Different patients are analyzed in Year 1 and Year 5
ISHLT 2007 J Heart Lung Transplant 2007;26
POST-LUNG TRANSPLANT MORBIDITY FOR PEDIATRICS Cumulative Prevalence in Survivors within 1 Year Post-Transplant
(Follow-ups: April 1994 - June 2006)
Outcome Within 1
Year
Total number with known response
Hypertension 39.4% (N = 480)
Renal Dysfunction 8.7% (N=483)
Abnormal Creatinine < 2.5 mg/dl 5.6% Creatinine > 2.5 mg/dl 2.3% Chronic Dialysis 0.6% Renal Transplant 0.2%
Hyperlipidemia 3.6% (N = 496)
Diabetes 25.8% (N = 484)
Bronchiolitis Obliterans 13.5% (N = 446)
ISHLT 2007 J Heart Lung Transplant 2007;26
POST-LUNG TRANSPLANT MORBIDITY FOR PEDIATRICS Cumulative Prevalence in Survivors within 5 Years Post-Transplant
(Follow-ups: April 1994 - June 2006)
Outcome Within 5
Years Total number with known response
Hypertension 65.0% (N = 123)
Renal Dysfunction 22.6% (N = 124) Abnormal Creatinine < 2.5 mg/dl 15.3% Creatinine > 2.5 mg/dl 4.0% Chronic Dialysis 1.6% Renal Transplant 1.6%
Hyperlipidemia 7.9% (N = 126)
Diabetes 35.5% (N = 124)
Bronchiolitis Obliterans 34.7% (N = 95)
ISHLT 2007 J Heart Lung Transplant 2007;26
POST-LUNG TRANSPLANT MORBIDITY FOR PEDIATRICS Cumulative Prevalence in Survivors within 7 Years Post-Transplant
(Follow-ups: April 1994 - June 2006)
Outcome Within 7
Years
Total number with known response
Hypertension 74.5% (N = 55)
Renal Dysfunction 36.2% (N = 58) Abnormal Creatinine < 2.5 mg/dl 24.1% Creatinine > 2.5 mg/dl 5.2% Chronic Dialysis 0.0% Renal Transplant 6.9%
Hyperlipidemia 5.2% (N = 58)
Diabetes 31.6% (N = 57)
Bronchiolitis Obliterans 28.6% (N = 35)
ISHLT 2007 J Heart Lung Transplant 2007;26
Freedom from Bronchiolitis Obliterans For Pediatric Lung Recipients (Follow-ups: April 1994 - June 2006)
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7
Years
% F
ree f
rom
Bro
nch
ioliti
s O
blite
ran
s
ISHLT 2007 J Heart Lung Transplant 2007;26
FREEDOM FROM BRONCHIOLITIS OBLITERANSFor Pediatric Lung Recipients by Induction Use
(Transplants: April 1994 - June 2006)
0
25
50
75
100
0 1 2 3 4 5 6 7
Years
Induction (N = 129)
No Induction (N = 306)
p = 0.2297
% F
ree fro
m B
ron
ch
iolit
is O
blit
era
ns
ISHLT 2007 J Heart Lung Transplant 2007;26
Freedom from Severe Renal Dysfunction*For Pediatric Lung Recipients (Follow-ups: April 1994 - June 2006)
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7Years
% F
ree f
rom
Severe
Ren
al
Dysfu
ncti
on
* Severe renal dysfunction = Creatinine > 2.5 mg/dl (221 μmol/L), dialysis or renal transplant
ISHLT 2007 J Heart Lung Transplant 2007;26
MALIGNANCY POST-LUNG TRANSPLANTATION FOR PEDIATRICSCumulative Incidence for Survivors (Follow-ups: April 1994 - June 2006)
Malignancy/Type 1-Year Survivors
5-Year Survivors
7-Year Survivors
No Malignancy 469 (94.6%) 111 (88.1%) 51 (87.9%)
Malignancy (all types combined)
27 (5.4%) 15 (11.9%) 7 (12.1%)
Malignancy Type
Lymph 24 14 6
Other 3 1 1
”Other” includes Liver and primitive neuroectodermal tumor.
ISHLT 2007 J Heart Lung Transplant 2007;26
Freedom from MalignancyFor Pediatric Lung Recipients (Follow-ups: April 1994 - June 2006)
50
60
70
80
90
100
0 1 2 3 4 5 6 7
Years
% F
ree
from
Mal
igna
ncy
All malignancy Lymph Skin Other
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG TRANSPLANT RECIPIENTS: Cause Of Death(Deaths: January 1992- June 2006)
CAUSE OF DEATH0-30 Days
(N =72 )31 Days - 1 Year
(N = 107)
>1 Year - 3 Years
(N = 111)
>3 Years - 5 Years
(N = 56)
>5 Years
(N = 38)
BRONCHIOLITIS 9 (8.4%) 43 (38.7%) 24 (42.9%) 16 (42.1%)
ACUTE REJECTION 1 (1.4%) 3 (2.8%) 1 (1.8%)
LYMPHOMA 3 (2.8%) 4 (3.6%) 2 (3.6%) 4 (10.5%)
MALIGNANCY, NON-LYMPHOMA
1 (1.8%)
CMV 6 (5.6%)
INFECTION, NON-CMV 9 (12.5%) 44 (41.1%) 23 (20.7%) 13 (23.2%) 3 (7.9%)
GRAFT FAILURE 24 (33.3%) 20 (18.7%) 21 (18.9%) 7 (12.5%) 8 (21.1%)
CARDIOVASCULAR 9 (12.5%) 4 (3.7%) 2 (1.8%)
TECHNICAL 10 (13.9%) 1 (0.9%)
MULTIPLE ORGAN FAILURE
6 (8.3%) 9 (8.4%) 9 (8.1%) 3 (5.4%) 3 (7.9%)
OTHER 13 (18.1%) 8 (7.5%) 9 (8.1%) 5 (8.9%) 4 (10.5%)
ISHLT 2007 J Heart Lung Transplant 2007;26
PEDIATRIC LUNG TRANSPLANT RECIPIENTS: Cause Of Death(Deaths: April 1994- June 2006)
CAUSE OF DEATH0-30 Days
(N =60 )31 Days - 1 Year
(N = 91)
>1 Year - 3 Years
(N = 103)
>3 Years - 5 Years
(N = 55)
>5 Years
(N = 38)
BRONCHIOLITIS 9 (9.9%) 40 (38.8%) 24 (43.6%) 16 (42.1%)
ACUTE REJECTION 1 (1.7%) 1 (1.1%) 1 (1.8%)
LYMPHOMA 1 (1.1%) 3 (2.9%) 2 (3.6%) 4 (10.5%)
MALIGNANCY, NON-LYMPHOMA
1 (1.8%)
CMV 5 (5.5%)
INFECTION, NON-CMV 8 (13.3%) 37 (40.7%) 21 (20.4%) 13 (23.6%) 3 (7.9%)
GRAFT FAILURE 17 (28.3%) 19 (20.9%) 21 (20.4%) 7 (12.7%) 8 (21.1%)
CARDIOVASCULAR 7 (11.7%) 3 (3.3%) 1 (1.%)
TECHNICAL 9 (15.%)
MULTIPLE ORGAN FAILURE
6 (10.%) 9 (9.9%) 9 (8.7%) 3 (5.5%) 3 (7.9%)
OTHER 12 (20.%) 7 (7.7%) 8 (7.8%) 4 (7.3%) 4 (10.5%)
ISHLT 2007 J Heart Lung Transplant 2007;26