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11
What makes an allograft marginal & Methods of
evaluation: HeartsHearts
Steven SL TsuiSteven SL TsuiDirector of Transplantation,Director of Transplantation,
Papworth Hospital, Cambridge, U.K.Papworth Hospital, Cambridge, U.K.
British Transplant Society Congress 2010Pre-congress Clinical Symposium
Tuesday 16th March 2010
Papworth HospitalNHS Foundation Trust
NHS
22
Heart TransplantHeart Transplant
Papworth HospitalNHS Foundation Trust
NHS
19671st successful HTx
19671st successful HTx
1990199019801980 2000200019701970 20102010
19791st successful UK HTx
19791st successful UK HTx
StandardDonor Criteria
StandardDonor Criteria
33
NUMBER OF HEART TRANSPLANTSNUMBER OF HEART TRANSPLANTS REPORTED BY YEARREPORTED BY YEAR
189 318665
1182
2159
2713
31363363
40034171 4203
4364 4429 4396 4263 41993864
3581 3433 3390 3283 3226 3065 3185 3205
0
500
1000
1500
2000
2500
3000
3500
4000
4500
Nu
mb
er
of
Tra
ns
pla
nts
ISHLT
2008NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as evidence that the number of hearts transplanted worldwide has declined in recent years. J Heart Lung Transplant 2008;27: 937-983
44
Heart TransplantHeart Transplant
Papworth HospitalNHS Foundation Trust
NHS
19671st successful HTx
19671st successful HTx
1990199019801980 2000200019701970 20102010
19791st successful UK HTx
19791st successful UK HTx
StandardDonor Criteria
StandardDonor Criteria
55
Heart TransplantHeart Transplant
Papworth HospitalNHS Foundation Trust
NHS
19671st successful HTx
19671st successful HTx
1990199019801980 2000200019701970 20102010
19791st successful UK HTx
19791st successful UK HTx
StandardDonor Criteria
StandardDonor Criteria
Older DonorsOlder Donors
LongerIschaemicTimes
LongerIschaemicTimes
Valve RepairValve Repair
Hep C+VEHep C+VE
LV HypertrophyLV Hypertrophy
CoronaryDiseaseCoronaryDisease
NHBDNHBD
Drug AbuseDrug Abuse
Brain MalignancyBrain Malignancy
CardiacArrestCardiacArrest
PoisonPoison
66
Heart Transplant Rates Heart Transplant Rates 20062006
7.4
6.9 6.8
6.1 6.1 6
5.55 5
4.4
3.83.5 3.5 3.4 3.2
2.92.6 2.5 2.4 2.2 2
0.90.6 0.6
0.30
1
2
3
4
5
6
7
8
He
art
Tx
pe
r m
illio
n p
op
ula
tio
n
Belgi
um
Austria
Norway
Fran
ce
Spain
Italy
Czech
German
y
Denm
ark
Sweden
Portugal
Slove
nia
Switzer
land
Finl
and
Croat
ia
Lith
uani
aUK
Poland
Nether
lands
Hungar
y
Slova
kia
Latv
ia
Greec
e
Turk
ey
Roman
ia
Papworth HospitalNHS Foundation Trust
NHS
2009 UK Heart Transplant Rate
77
Variations in Variations in Heart Transplant RatesHeart Transplant Rates
Heart donation rateHeart donation rate Yield rate:Yield rate:
19% to 62% (mean 39%)19% to 62% (mean 39%)11
Donor cause of deathDonor cause of death Donor ageDonor age Threshold for using marginal organsThreshold for using marginal organs
Even in the most aggressive program, a significant % of Even in the most aggressive program, a significant % of donated hearts are not transplanteddonated hearts are not transplanted
1 1999 survey by Assoc. of Organ Procurement Organizations (AOPO)
Papworth HospitalNHS Foundation Trust
NHS
88
GRAFT FAILURE42%
CARDIAC ALLOGRAFT VASCULOPATHY
ACUTE REJECTION
LYMPHOMA
MALIGNANCY, OTHER
CMV
INFECTION, NON-CMV
GRAFT FAILURE
TECHNICAL
OTHER
MULTIPLE ORGAN FAILURE
RENAL FAILURE
PULMONARY
CEREBROVASCULAR
ADULT HEART TRANSPLANT ADULT HEART TRANSPLANT RECIPIENTS: RECIPIENTS:
Cause of Death Cause of Death (Deaths: January 1992 - June 2006)(Deaths: January 1992 - June 2006)
ISHLT 2008J Heart Lung Transplant 2008;27: 937-983
Papworth HospitalNHS Foundation Trust
NHS
99
Definition of High Risk Donor (HRD):Definition of High Risk Donor (HRD): Donor age > 40 yrDonor age > 40 yr High dose inotropes (dopamine > 12 High dose inotropes (dopamine > 12 μμg.kgg.kg-1-1.min.min-1 -1 )) CPR > 5 minutesCPR > 5 minutes Elevated CK-MBElevated CK-MB D/R weight ratio < 80%D/R weight ratio < 80% Wall motion abnormalityWall motion abnormality Rhythm disturbancesRhythm disturbances Total ischemic time > 5 hrsTotal ischemic time > 5 hrs
HRD accounted for HRD accounted for 38.3%38.3% of 188 heart of 188 heart transplants between 1985-92 in Oregontransplants between 1985-92 in Oregon
A 1994 Definition of A 1994 Definition of Marginal Donor HeartMarginal Donor Heart
Ott et al. Ann Thorac Surg 1994;57:76-82
Papworth HospitalNHS Foundation Trust
NHS
1010
Definition of Marginal Donor:Definition of Marginal Donor: Donor age > 55 yearsDonor age > 55 years cocaine or intravenous drug usecocaine or intravenous drug use diabetes mellitusdiabetes mellitus hepatitis C +vehepatitis C +ve EF < 45%EF < 45% D:R weight ratio < 0.7D:R weight ratio < 0.7
UNOS Jan 1999 – Dec 2005: 13,024 heart UNOS Jan 1999 – Dec 2005: 13,024 heart transplantstransplants
Marginal donors, Marginal donors, 10.2% of all Heart Tx in USA10.2% of all Heart Tx in USA
A 2009 Definition of A 2009 Definition of Marginal Donor HeartMarginal Donor Heart
Russo et al. Ann Thorac Surg 2009;87:1066–71
Papworth HospitalNHS Foundation Trust
NHS
1111
ADULT HEART TRANSPLANTS ADULT HEART TRANSPLANTS (1/2002-6/2006)(1/2002-6/2006) Relative Risk of 1 Year Mortality with 95% Confidence LimitsRelative Risk of 1 Year Mortality with 95% Confidence Limits
Donor AgeDonor Age
0
0.5
1
1.5
2
2.5
15 20 25 30 35 40 45 50 55 60
Donor Age
p < 0.0001
Re
lati
ve
Ris
k o
f 1
Ye
ar
Mo
rta
lity
2008ISHLT (N=8,823)J Heart Lung Transplant 2008;27: 937-983
1212
ADULT HEART TRANSPLANTS ADULT HEART TRANSPLANTS (1/2002-6/2006)(1/2002-6/2006) Relative Risk of 1 Year Mortality with 95% Confidence LimitsRelative Risk of 1 Year Mortality with 95% Confidence Limits
Donor BMIDonor BMI
0
0.5
1
1.5
18 20 22 24 26 28 30 32 34
Donor BMI (kg/m2)
p = 0.0288
Re
lati
ve
Ris
k o
f 1
Ye
ar
Mo
rta
lity
2008ISHLT (N=8,823)J Heart Lung Transplant 2008;27: 937-983
1313
ADULT HEART TRANSPLANTS ADULT HEART TRANSPLANTS (1/2002-6/2006)(1/2002-6/2006) Relative Risk of 1 Year Mortality with 95% Confidence LimitsRelative Risk of 1 Year Mortality with 95% Confidence Limits
Ischemia TimeIschemia Time
0
0.5
1
1.5
2
30 60 90 120 150 180 210 240 270 300 330 360
Ischemia Time (minutes)
p = 0.0060Re
lati
ve
Ris
k o
f 1
Ye
ar
Mo
rta
lity
2008ISHLT (N=8,823)J Heart Lung Transplant 2008;27: 937-983
1414
ADULT HEART TRANSPLANTSADULT HEART TRANSPLANTS (1/2002-(1/2002-6/2006) 6/2006)
Factors Factors NotNot Significant for 1 Year Mortality Significant for 1 Year Mortality
Recipient Factors: Prior malignancy, gender, hospitalized, prior pregnancy, balloon pump, diabetes, PRA
Donor Factors: Clinical infection, history of diabetes, gender, history of hypertension, cause of death, history of malignancy
Transplant Factors: HLA mismatch, CMV mismatch, prior transplant
2008ISHLT J Heart Lung Transplant 2008;27: 937-983
1515
Organs that fail to meet 1 or more of the Organs that fail to meet 1 or more of the traditional criteria for an optimal cardiac traditional criteria for an optimal cardiac donordonor
Consensus Conference Consensus Conference Definition of Marginal Donor Definition of Marginal Donor
HeartHeart
1 Zaroff et al. Circulation. 2002;106:836-841
Papworth HospitalNHS Foundation Trust
NHS
1616
Extra Cardiac FactorsExtra Cardiac Factors
Donor age < 55 y.o.Donor age < 55 y.o. Donor medical historyDonor medical history
Recent cardiac arrest Recent cardiac arrest Hep C +veHep C +ve Risk of coronary disease: smoking, hypertension, Risk of coronary disease: smoking, hypertension,
diabetes, lipidsdiabetes, lipids Donor lifestyleDonor lifestyle
Cocaine useCocaine use IV drug abuseIV drug abuse Unprotected sex/multiple partnersUnprotected sex/multiple partners
Donor/recipient size mismatchDonor/recipient size mismatch
Papworth HospitalNHS Foundation Trust
NHS
1717
Structural AbnormalitiesStructural Abnormalities
Coronary artery diseaseCoronary artery disease LV hypertrophyLV hypertrophy Valvular abnormalityValvular abnormality Congenital lesionsCongenital lesions
Bicuspid AVBicuspid AV Secundum ASDSecundum ASD
Papworth HospitalNHS Foundation Trust
NHS
1818
Functional AbnormalitiesFunctional Abnormalities
EchocardiogramEchocardiogram EF > 45%EF > 45%
Hemodynamic targetsHemodynamic targets CVP CVP < 12 mmHg< 12 mmHg PCWP PCWP < 12 mmHg < 12 mmHg MAP MAP > 60 mmHg> 60 mmHg C.I.C.I. > 2.4 L.min> 2.4 L.min-1-1.m.m-2-2
SVRSVR 800 – 1200 dyne.sec800 – 1200 dyne.sec-1-1.cm.cm-5-5
Dopamine/dobutamine > 10 Dopamine/dobutamine > 10 μμg.kgg.kg-1-1.min.min-1-1
Papworth HospitalNHS Foundation Trust
NHS
1919
Donor Heart AssessmentDonor Heart Assessment
BiochemicalBiochemical StructuralStructural
ECG ECG EchocardiogramEchocardiogram Coronary angiogramCoronary angiogram
Functional Functional EchocardiogramEchocardiogram Invasive monitoringInvasive monitoring
Papworth HospitalNHS Foundation Trust
NHS
2020
Biochemical MarkersBiochemical Markers
CK-MBCK-MB TroponinTroponin
Anderson et al. Transplantation. 1994;58:1056-57 Vijay et al. Ann Thorac Surg. 1998;66:1934-39
Pro-calcitoninPro-calcitonin Venkateswaran et al. Transplantation. 2009;88:582-8
TNF-alphaTNF-alpha SMARCAL-1SMARCAL-1
Aharinejad et al. Circulation. 2009;120:S198-205
Papworth HospitalNHS Foundation Trust
NHS
2121
Structural AssessmentStructural Assessment
ECG criteriaECG criteria S in V1 + R in V5/V6 > 35 mm
EchocardiogramEchocardiogram Posterior wall or septum > 12 mmPosterior wall or septum > 12 mm
Associated risk factors:Associated risk factors: History of hypertensionHistory of hypertension Ischaemic time > 180 min.Ischaemic time > 180 min.
1 Marelli et al. J Heart Lung Transplant. 2000;19:496-503
Papworth HospitalNHS Foundation Trust
NHS
2222
Coronary AngiographyCoronary Angiography
1 1 Recommended: Recommended: Male Male > 45 yr> 45 yr FemaleFemale > 50 yr> 50 yr
Consider in > 35 y.o. if Consider in > 35 y.o. if cocaine use cocaine use >2 risk factors>2 risk factors
22 Bench coronary cine-angiography Bench coronary cine-angiography1 Zaroff et al. Circulation. 2002;106:836-8412 Robiscek et al. JTCVS 1992;102:490-5
Hypertension Diabetes Smoking
Dyslipidemia Family history of CAD
Papworth HospitalNHS Foundation Trust
NHS
2323
Functional AssessmentFunctional Assessment
Serial echocardiogramSerial echocardiogram Stress echocardiogram Stress echocardiogram 11
DipyridamolDipyridamol DobutamineDobutamine
Invasive hemodynamic assessmentInvasive hemodynamic assessment
1 Leone et al. J Heart Lung Transplant. 2009;28:1141-9
Papworth HospitalNHS Foundation Trust
NHS
2424
Hemodynamic MonitoringHemodynamic Monitoring
Swan-Ganz provides:Swan-Ganz provides: PreloadPreload - CVP / - CVP /
PCWPPCWP AfterloadAfterload - SVR- SVR
Cardiac output Cardiac output trendstrends
Papworth HospitalNHS Foundation Trust
NHS
Wheeldon et al. J Heart Lung Transplant 1995;14:734-8 Venkateswaran et al. Eur Heart J 2009;30:1771-80
2525
Principles of Donor Principles of Donor Resuscitation:Resuscitation:
Papworth ProtocolPapworth Protocol Achieve isovolaemiaAchieve isovolaemia Acid-base balance Acid-base balance
Powner et al. Prog Transplant 2000;10:25Powner et al. Prog Transplant 2000;10:25
Minimise catecholamine Minimise catecholamine Hormone replacement Hormone replacement
Novitzky et al. Transplantation. 1987;43:852-9
Vasopressin for: Vasopressin for: Pennefather et al. Transplantation Pennefather et al. Transplantation 1990;49:3111990;49:311
diabetes insipidusdiabetes insipidus vascular tonevascular tone
Wheeldon et al. J Heart Lung Transplant 1995;14:734-8Zaroff et al. Circulation. 2002;106:836-41
Papworth HospitalNHS Foundation Trust
NHS
2626
“……“…….. it makes little sense to replace .. it makes little sense to replace one diseased heart with another.”one diseased heart with another.”
N. DePasquale N. DePasquale
Editorial: how normal is the donor heart?Editorial: how normal is the donor heart?
Am Heart J 1969;77:719Am Heart J 1969;77:719
…………………….unless it can confer significant .unless it can confer significant prognostic benefit to the recipient.prognostic benefit to the recipient.
Papworth HospitalNHS Foundation Trust
NHS
2727
2828
The Alternate Recipient List for The Alternate Recipient List for Heart TransplantHeart Transplant
1 Laks et al. J Heart Lung Transplant. 1997;16:735-42
Standard Donor Heart
Marginal Donor Heart
Status 1 Patient
Status 2 Patient
Status 1 Patient
Alternate Recipient since
1992
Papworth HospitalNHS Foundation Trust
NHS
2929
3030
ADULT HEART TRANSPLANT RECIPIENTS: ADULT HEART TRANSPLANT RECIPIENTS: Cause of Death Cause of Death (Deaths: January 1992 - June 2006)(Deaths: January 1992 - June 2006)
CAUSE OF DEATHCAUSE OF DEATH 0-30 Days 0-30 Days
(N = (N = 3,006)3,006)
31 Days – 31 Days –
1 Year1 Year
(N = (N = 2,722)2,722)
>1 Year – >1 Year –
3 Years 3 Years
(N = (N = 2,135)2,135)
>3 Years – >3 Years –
5 Years 5 Years
(N = 1,857)(N = 1,857)
>5 Years – >5 Years –
10 Years10 Years
(N = (N = 4,054)4,054)
>10 Years>10 Years
(N = 2,107)(N = 2,107)
CARDIAC ALLOGRAFT CARDIAC ALLOGRAFT VASCULOPATHYVASCULOPATHY 52 (1.7%)52 (1.7%) 127 (4.7%)127 (4.7%) 298 298
(14.0%)(14.0%) 299 (16.1%)299 (16.1%) 581 581 (14.3%)(14.3%) 309 (14.7%)309 (14.7%)
ACUTE REJECTIONACUTE REJECTION 193 (6.4%)193 (6.4%) 338 338 (12.4%)(12.4%)
220 220 (10.3%)(10.3%) 82 (4.4%)82 (4.4%) 69 (1.7%)69 (1.7%) 26 (1.2%)26 (1.2%)
LYMPHOMALYMPHOMA 2 (0.1%)2 (0.1%) 54 (2.0%)54 (2.0%) 85 (4.0%)85 (4.0%) 96 (5.2%)96 (5.2%) 195 (4.8%)195 (4.8%) 73 (3.5%)73 (3.5%)
MALIGNANCY, OTHERMALIGNANCY, OTHER 1 (0.0%)1 (0.0%) 57 (2.1%)57 (2.1%) 218 218 (10.2%)(10.2%) 340 (18.3%)340 (18.3%) 749 749
(18.5%)(18.5%) 392 (18.6%)392 (18.6%)
CMVCMV 4 (0.1%)4 (0.1%) 34 (1.2%)34 (1.2%) 16 (0.7%)16 (0.7%) 3 (0.2%)3 (0.2%) 5 (0.1%)5 (0.1%) 1 (0.0%)1 (0.0%)
INFECTION, NON-CMVINFECTION, NON-CMV 393 393 (13.1%)(13.1%)
896 896 (32.9%)(32.9%)
276 276 (12.9%)(12.9%) 180 (9.7%)180 (9.7%) 442 442
(10.9%)(10.9%) 213 (10.1%)213 (10.1%)
GRAFT FAILUREGRAFT FAILURE 1,257 1,257 (41.8%)(41.8%) 500 (18.4%)500 (18.4%) 499 (23.4%)499 (23.4%) 379 (20.4%)379 (20.4%) 765 (18.9%)765 (18.9%) 353 (16.8%)353 (16.8%)
TECHNICALTECHNICAL 233 (7.8%)233 (7.8%) 28 (1.0%)28 (1.0%) 17 (0.8%)17 (0.8%) 17 (0.9%)17 (0.9%) 36 (0.9%)36 (0.9%) 20 (0.9%)20 (0.9%)
OTHEROTHER 162 (5.4%)162 (5.4%) 175 (6.4%)175 (6.4%) 187 (8.8%)187 (8.8%) 147 (7.9%)147 (7.9%) 339 (8.4%)339 (8.4%) 175 (8.3%)175 (8.3%)
MULTIPLE ORGAN MULTIPLE ORGAN FAILUREFAILURE
356 356 (11.8%)(11.8%) 268 (9.8%)268 (9.8%) 117 (5.5%)117 (5.5%) 102 (5.5%)102 (5.5%) 309 (7.6%)309 (7.6%) 190 (9.0%)190 (9.0%)
RENAL FAILURERENAL FAILURE 20 (0.7%)20 (0.7%) 25 (0.9%)25 (0.9%) 36 (1.7%)36 (1.7%) 65 (3.5%)65 (3.5%) 225 (5.6%)225 (5.6%) 173 (8.2%)173 (8.2%)
PULMONARYPULMONARY 133 (4.4%)133 (4.4%) 108 (4.0%)108 (4.0%) 96 (4.5%)96 (4.5%) 85 (4.6%)85 (4.6%) 172 (4.2%)172 (4.2%) 99 (4.7%)99 (4.7%)
CEREBROVASCULARCEREBROVASCULAR 200 (6.7%)200 (6.7%) 112 (4.1%)112 (4.1%) 70 (3.3%)70 (3.3%) 62 (3.3%)62 (3.3%) 167 (4.1%)167 (4.1%) 83 (3.9%)83 (3.9%)
ISHLT
Last updated based on data as of December 2006 J Heart Lung Transplant 2008;27: 937-983
3131
ADULT HEART TRANSPLANT RECIPIENTS: ADULT HEART TRANSPLANT RECIPIENTS: Cause of Death Cause of Death (Deaths: January 1992 - June 2006)(Deaths: January 1992 - June 2006)
CAUSE OF DEATHCAUSE OF DEATH 0-30 Days 0-30 Days
(N = (N = 3,006)3,006)
31 Days – 31 Days –
1 Year1 Year
(N = (N = 2,722)2,722)
>1 Year – >1 Year –
3 Years 3 Years
(N = (N = 2,135)2,135)
>3 Years – >3 Years –
5 Years 5 Years
(N = 1,857)(N = 1,857)
>5 Years – >5 Years –
10 Years10 Years
(N = (N = 4,054)4,054)
>10 Years>10 Years
(N = 2,107)(N = 2,107)
CARDIAC ALLOGRAFT CARDIAC ALLOGRAFT VASCULOPATHYVASCULOPATHY 52 (1.7%)52 (1.7%) 127 (4.7%)127 (4.7%) 298 298
(14.0%)(14.0%) 299 (16.1%)299 (16.1%) 581 581 (14.3%)(14.3%) 309 (14.7%)309 (14.7%)
ACUTE REJECTIONACUTE REJECTION 193 (6.4%)193 (6.4%) 338 338 (12.4%)(12.4%)
220 220 (10.3%)(10.3%) 82 (4.4%)82 (4.4%) 69 (1.7%)69 (1.7%) 26 (1.2%)26 (1.2%)
LYMPHOMALYMPHOMA 2 (0.1%)2 (0.1%) 54 (2.0%)54 (2.0%) 85 (4.0%)85 (4.0%) 96 (5.2%)96 (5.2%) 195 (4.8%)195 (4.8%) 73 (3.5%)73 (3.5%)
MALIGNANCY, OTHERMALIGNANCY, OTHER 1 (0.0%)1 (0.0%) 57 (2.1%)57 (2.1%) 218 218 (10.2%)(10.2%) 340 (18.3%)340 (18.3%) 749 749
(18.5%)(18.5%) 392 (18.6%)392 (18.6%)
CMVCMV 4 (0.1%)4 (0.1%) 34 (1.2%)34 (1.2%) 16 (0.7%)16 (0.7%) 3 (0.2%)3 (0.2%) 5 (0.1%)5 (0.1%) 1 (0.0%)1 (0.0%)
INFECTION, NON-CMVINFECTION, NON-CMV 393 393 (13.1%)(13.1%)
896 896 (32.9%)(32.9%)
276 276 (12.9%)(12.9%) 180 (9.7%)180 (9.7%) 442 442
(10.9%)(10.9%) 213 (10.1%)213 (10.1%)
GRAFT FAILUREGRAFT FAILURE 1,257 1,257 (41.8%)(41.8%) 500 (18.4%)500 (18.4%) 499 (23.4%)499 (23.4%) 379 (20.4%)379 (20.4%) 765 (18.9%)765 (18.9%) 353 (16.8%)353 (16.8%)
TECHNICALTECHNICAL 233 (7.8%)233 (7.8%) 28 (1.0%)28 (1.0%) 17 (0.8%)17 (0.8%) 17 (0.9%)17 (0.9%) 36 (0.9%)36 (0.9%) 20 (0.9%)20 (0.9%)
OTHEROTHER 162 (5.4%)162 (5.4%) 175 (6.4%)175 (6.4%) 187 (8.8%)187 (8.8%) 147 (7.9%)147 (7.9%) 339 (8.4%)339 (8.4%) 175 (8.3%)175 (8.3%)
MULTIPLE ORGAN MULTIPLE ORGAN FAILUREFAILURE
356 356 (11.8%)(11.8%) 268 (9.8%)268 (9.8%) 117 (5.5%)117 (5.5%) 102 (5.5%)102 (5.5%) 309 (7.6%)309 (7.6%) 190 (9.0%)190 (9.0%)
RENAL FAILURERENAL FAILURE 20 (0.7%)20 (0.7%) 25 (0.9%)25 (0.9%) 36 (1.7%)36 (1.7%) 65 (3.5%)65 (3.5%) 225 (5.6%)225 (5.6%) 173 (8.2%)173 (8.2%)
PULMONARYPULMONARY 133 (4.4%)133 (4.4%) 108 (4.0%)108 (4.0%) 96 (4.5%)96 (4.5%) 85 (4.6%)85 (4.6%) 172 (4.2%)172 (4.2%) 99 (4.7%)99 (4.7%)
CEREBROVASCULARCEREBROVASCULAR 200 (6.7%)200 (6.7%) 112 (4.1%)112 (4.1%) 70 (3.3%)70 (3.3%) 62 (3.3%)62 (3.3%) 167 (4.1%)167 (4.1%) 83 (3.9%)83 (3.9%)
ISHLT
Last updated based on data as of December 2006 J Heart Lung Transplant 2008;27: 937-983