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OBJECTIVES: We developed a new algorithm to identify high-risk patients for underweight after oesophagectomy for cancer. Patients were assigned to an age–gender-specific body mass index percentile (AG-BMI) which is then used in a survival analysis. This model was able to identify patients more at risk for being underweight in comparison with the classically used BMI. It shows a worse overall survival (OS) in patients with a preoperative AG-BMI < 10th percentile. The aim of this study is to validate this new model based on a cohort of patients from an external high-volume institution specialized in oesophageal cancer surgery. METHODS: The validation cohort consists of 407 patients operated on between 1999 and 2012 with the prerequisite data to calculate AGBMI and OS. The base cohort consisted of 642 consecutive patients, operated on in our institution between 2005 and 2010. Age, gender, height and weight on the day before surgery were used to calculate the BMI and the AG-BMI. OS was analysed and a multivariate analysis was performed. RESULTS: Incidence rates of the AG-BMI < 10th percentile risk-patients in the validation cohort showed similar results to our original results (17.8 vs 17.2% for the base cohort) with a similar significant OS difference between at-risk patients and not-at-risk patients (P < 0.001). Multivariate analysis found the same five independent prognosticators for OS in both datasets: age, early versus advanced disease, resection status, number of positive lymph nodes and the AG-BMI 10th percentile, but not BMI itself. In the validation cohort, gender was identified as an additional independent prognosticator. The worse OS survival in AG-BMI < 10th percentile in both patient populations was related to a significantly higher number of deaths without oesophageal cancer recurrence. CONCLUSIONS: This study validates the newly developed AG-BMI model to predict more accurately a subgroup of patients at risk for worse survival after oesophagectomy. Improved perioperative identification of risk factors for poorer OS could help to develop perioperative strategies to reduce these risks.

OBJECTIVES: Donor to recipient (D/R) matching in lung transplantation (LTx) is usually directed by blood group (identity or compatibility) and predicted total lung capacity (pTLC) based on height and age. Other donor (D) and recipient (R) characteristics such as cytomegalovirus (CMV) serology (±), gender [male (M)/ female (F)] and age are often ignored, but the impact of D/R mismatch for these variables and their combinations on outcome is less investigated. METHODS: The early and late outcomes in 461 lung recipients (149 single-lung and 312 double-lung) transplanted between July 1991 and December 2009 were explored, comparing different D/R combinations for gender (M/F), age (

OBJECTIVES The current (7th) International Union Against Cancer (UICC) pN staging system is based on the number of positive lymph nodes but does not take into consideration the characteristics of the metastatic lymph nodes itself. In particular, it has been suggested that tumour penetration beyond the lymph node capsule in metastatic lymph nodes, which is also called extracapsular lymph node involvement, has a prognostic impact. The aim of the current study was to assess the prognostic value of extracapsular (EC) and intracapsular (IC) lymph node involvement (LNI) in adenocarcinoma of the oesophagus and gastro-oesophageal junction (GOJ) and to assess its potential impact on the 7th edition of the UICC TNM manual. METHODS From 2000 to 2010, all consecutive adenocarcinoma patients with primary R0-resection (n = 499) were prospectively included for analysis. The number of resected lymph nodes, number of positive lymph nodes and number of EC-LNI/IC-LNI were determined. Extracapsular spread was defined as infiltration of cancer cells beyond the capsule of the positive lymph node. RESULTS Two hundred and eighteen (43%) patients had positive lymph nodes. Cancer-specific 5-year survival in lymph node-positive patients was significantly (P < 0.0001) worse compared with lymph node-negative patients, being 88.3 vs 28.7%, respectively. In 128 (58.7%) cases EC-LNI was detected. EC-LNI showed significantly worse cancer-specific 5-year survival compared with IC-LNI, 19.6 vs 44.0% (P < 0.0001). In the pN1 category (1 or 2 positive LN's-UICC stages IIB and IIIA), this was 30.4% vs 58%; (P = 0.029). In higher pN categories, this effect was no longer noticed. Integrating these findings into an adapted TNM classification resulted in improved homogeneity, monotonicity of gradients and discriminatory ability indicating an improved performance of the staging system. CONCLUSIONS EC-LNI is associated with worse survival compared with IC-LNI. EC-LNI patients show survival rates that are more closely associated with the current TNM stage IIIB, while IC-LNI patients have a survival more similar to TNM stage IIB. Incorporating the EC-IC factor in the TNM classification results in an increased performance of the TNM model. Further confirmation from other centres is required within the context of future adaptations of the UICC/AJCC (American Joint Committee on Cancer) staging system for oesophageal cancer.

OBJECTIVES: Preventive antireflux surgery (ARS) at the moment of congenital diaphragmatic hernia (CDH) repair has been suggestedby some authors, particularly in subgroups with a liver herniated in the chest or patch requirement. We evaluated the incidence andassociated factors of gastro-oesophageal reflux disease (GERD) and the need for subsequent ARS in our CDH patients.METHODS: We retrospectively reviewed our CDH database. Demographics, prenatal assessment of severity, prenatal treatment, type ofrepair, intraoperative findings and incidences of gastro-oesophageal reflux and ARS were recorded.RESULTS: CDH repair was performed in 77 infants between July 1993 and November 2009. Eight died after repair. Seven were lost tofollow-up. The median follow-up was 4.0 (0.16–14.88) years. Fourteen of these 62 patients were prenatally treated with fetoscopicendoluminal tracheal occlusion (FETO) because of severe pulmonary hypoplasia. After CDH repair, GERD was diagnosed in 31 patients.In all of them, medical antireflux treatment was started. Thirteen (42%) patients needed ARS at a median age of 64 (37–264) days. Oneyear after starting medical treatment, 14 (45%) patients were completely off antireflux medication. In CDH subgroups with patch repair,liver herniated in the chest or previous FETO, the incidences of gastro-oesophageal reflux and ARS were 61 and 32%, 73 and 38% and71 and 43%, respectively. Univariable analysis of associated potentially predisposing factors shows that patch repair, liver herniated inthe chest, pulmonary hypertension, high-frequency oscillatory ventilation and FETO are associated with subsequent ARS. On multivari-able analysis, liver herniated in the chest was the only independent predictor for both gastro-oesophageal reflux and ARS.CONCLUSIONS: Of all CDH patients, 50% developed gastro-oesophageal reflux and 21% required ARS. For both, liver in the chest wasthe only independent predictor. Routine ARS in certain subgroups at the time of CDH repair seems not to be justified. Foetal endolum-inal tracheal occlusion creates a new cohort of survivors with an increased risk for undergoing ARS. The surgical group, in particular,reflects a more complex gastro-oesophageal reflux physiopathology.Keywords: Gastro-oesophageal reflux † Congenital diaphragmatic hernia † Fundoplication

Objective: It remains uncertain whether donor cause of brain death (DCBD) affects survival and freedom from bronchiolitis obliterans syndrome(BOS)after lungtransplantation(LTx).Inaddition,itis unknownwhetherthelengthoftimeintervalfrombraininsulttobraindeath[BIBD] and from brain death to cold preservation [BD-CP] has an impact on outcome. Methods: Medical charts of isolated lung transplant recipients from 400 consecutive donors were reviewed and classified according to DCBD: 190 vascular [V], 185 traumatic [T], 25 others [O]. Demographics were compared between donor groups. Hospital outcome, survival, and freedom from BOS in recipients were analyzed in relation to DCBD and related time intervals. Results:Donor age, gender, and weight differed between donor groups (p < 0.001, p < 0.001, p < 0.05; respectively). No differences in recipient hospital outcome, survival, and freedom from BOS were found between groups. [BD-CP] longer than 10 h resulted in a survival advantage (69% vs 58% and 51% vs 42% at 5 and 10 years, respectively; p < 0.05) and a reduced hazard risk (0.952) of dying after LTx; (p < 0.05). Multivariable analysis failed to show a significant correlation between DCBD and [BI-BD] versus survival and BOS. Conclusion: DCBD and [BI-BD] do not affect survival and freedom from BOS after LTx. Lung recipients from donors certified brain dead with a time interval longer than 10 h prior to organ preservation showed improved survival unrelated to BOS. This may result from longer and better donor management with reduced lung injury. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Since 1992, various combinations of thoracoscopy (VATS), laparoscopy or hand-assisted thoracolaparoscopy have been used for 'minimally invasive' cancer esophagectomy (MIE). Despite widespread current use, indications and potential benefits of the many technical approaches remain controversial. A systematic literature search was conducted until June 2007. Out of 128 publications, 46 original series (1932 patients) met the inclusion criteria and were analyzed for surgical and oncological outcome. No prospective controlled study has compared any MIE technique to another or to open surgery. Most publications are retrospective series of highly selected patients, mostly excluding high-risk patients and locally advanced (T3) tumors. Altogether, the overall conversion rate was 5.9%, mortality 2.9% and morbidity 46%, many papers reporting only major complications. Overall, rates for pulmonary complications were 22%, leakage 8.8% and vocal cord palsy 7.1%. Fifteen tracheo-bronchial injuries or fistulas (1% of all VATS cases) were reported. Laparoscopy and VATS were combined in 11 series (609 patients, 4.7% conversions, 2.4% mortality). VATS combined with (mini)-laparotomy was reported in 14 papers (743 patients, 6.3% conversions, 2.4% mortality). Laparoscopy combined with right thoracotomy was reported in four papers (147 patients, 5.4% conversions, 2% mortality). Laparoscopic transhiatal resections were reported in 17 papers (433 patients, 7% conversions, 4.6% mortality). Overall morbidity rates for these four approaches were 43%, 47.6%, 51.6% and 46%, respectively. Data on oncological outcome are scarce. Lymph node retrieval (median of all series: 14 nodes, range 5-62) was mostly inferior to open surgery standards and follow-up too short to draw definitive conclusions regarding long-term survival. Based on the available literature, the morbidity and mortality of MIE is substantial and not inferior to radical open esophagectomy in experienced centers. Many different operative techniques for MIE have been reported without obvious superiority for any of them. The term 'minimally invasive' is not supported by hitherto reported results. Selection bias and huge variability in extent of resection and lymphadenectomy impair comparisons of different MIE techniques. Oncological outcome of MIE remains largely unknown by lack of good quality data and selection bias. MIE remains an investigational and still evolving treatment for invasive cancer.

Objective:Thoughthe surgicaltreatment of esophageal cancer is increasingly acceptedfor elderlypeopledefined as aged over70 years, less is reported about the results in patients over 75. This study is a single institution retrospective analysis of outcome after esophagectomy for cancer of the esophagus and GEJ in patients aged over 75 years. Methods: All consecutive patients 76 years old and over undergoing curative esophagectomy for cancer in the period 1991—2006 were analyzed as to comorbidities, outcome and long-term survival. All the data had been prospectivelycollectedinadatabase.PostoperativemortalityriskwasassessedbyP-POSSUMandO-POSSUMscoreforin-hospitalmortalityandby the recently published Steyerberg’s score system [Steyerberg EW, Neville BA, Koppert LB, Lemmens VEPP, Tilanus HW, Coebergh JWW, Weeks JC, Earle CC. Surgical mortality in patients with esophageal cancer: development and validation of a simple risk score. J Clin Oncol 2006;24:4277— 84.] for 30-day mortality. Five-year survival was compared to the standardized survival in the general population.Results:One hundred and eight patients fulfilling the abovementioned criteria were found (76 males and 32 females, mean age 79.5 years, mean standardized life-expectancy: 7.36 years). Among them, 69% had esophageal tumors and 31% GEJ tumors. The predominant histology was adenocarcinoma (74%). Eighty-six (79.6%) presented with one or more major comorbidities or a history of previous major upper-GI surgery, potentially affecting the surgical outcome. All underwent resection with curative intent (R0 83.3%, R1 12%, R2 4.6%). The overall postoperative morbidity rate was 51.9%, pulmonary complications (37%) being the most frequent. Postoperative mortality, mainly due to cardiopulmonary complications, was 7.4%, which was consistent with that predicted by P-POSSUM score (7.2%) and lower than that predicted by O-POSSUM score (15.1%). Thirty-day mortality was 5.5%, being consistent with that predicted by the Steyerberg’s score (6.8%). Overall 5-year survival was 35.7%, while R0 overall survival 42% and cancer specific R0 survival 51.7%. Conclusions: Patients 76 years old and over with esophageal or GEJ cancer should not be denied surgery solely on the basis of age. Outcome and long-term results in the selected elderly are not differing from those reported for younger patients. However, despite thorough preoperative assessment being applied in the selection of the candidates for surgery, a practical and reliable individual riskanalysis stratification is still lacking. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective: Very few studies have examined post-operative morbidity after resection of oesophageal carcinoma, especially in patients treated with induction chemo- and radiotherapy for locally advanced stages. This study assessed the effects of induction chemoradiotherapy on post-operative course after resection of locally advanced oesophageal carcinoma (cT3–4 þ cM1lymph). Methods: Induction therapy consisted of 5-fluorouracil days 1 – 5 and days 21 – 25, cisplatin day 1 þ day 21 and concomitant radiotherapy 18 – 20 fractions of 2 Gy (total dose 36 – 40 Gy). Induction chemoradiotherapy was completed in 109 patients. Surgery was performed in 90 patients (operability: 90=109 ¼ 83%): 85 patients underwent resection with curative intent (resectability: 85=109 ¼ 78%), bypass operation was performed in five patients. Nineteen patients could not be operated on. Results were compared to a matched group of pT3M1LYM/pT4 patients (n ¼ 86) who underwent primary surgery in the same period. Results: Resection was complete (R0) in 68 patients (68=90 ¼ 76%). Mean duration of surgery was 428 min (range: 240– 690). Peroperative complications were haemorrhage in three patients (3=90 ¼ 3:3%), tracheobronchial perforation in three patients (3=90 ¼ 3:3%). Median total hospital stay was 20.5 days (range: 8 – 355). Mean duration of intubation was 7 days (range: 1 – 190); 67 patients (67=90 ¼ 74:4%) were intubated for less than 24 h. Non-tumour related hospital mortality after resection was 8.3% (7/84 patients). Mortality after two-field lymphadenectomy was 5.2 versus 11.7% after three-field lymphadenectomy. After primary surgery (n ¼ 86) overall mortality was 2.3% (P ¼ 0:015) and nil after two- and three-field lymphadenectomy (P ¼ 0:011). Medical morbidity consisted of pneumonia in 43 patients (43=90 ¼ 48%), atelectasis in ten patients (10=90 ¼ 11%), dysrhythmia in 21 patients (21=90 ¼ 23%), sepsis in 11 patients (11=90 ¼ 12%) and adult respiratory distress syndrome in ten patients (10=90 ¼ 11%). Surgical morbidity included pleural effusion in 16 patients (16=90 ¼ 18%), tracheal fistula in two patients (2=90 ¼ 2%), chylothorax in two patients (2=90 ¼ 2%) and acute pancreatitis in one patient (1=90 ¼ 1%). Ten patients (10=90 ¼ 11%) had a radiologically confirmed anastomotic leak; however only in four out of them with clinical manifestation; treatment was conservative in all four patients. Major morbidity occurred in 27 patients (27=90 ¼ 30%). Overall rate of morbidity was significantly higher after three-field lymphadenectomy (85%) as compared to two-field lymphadenectomy (68.7%; P ¼ 0:023). Conclusions: Chemoradiotherapy followed by resection of cT3– 4 þ /2 cM1lymph oesophageal carcinoma is feasible with acceptable mortality. Mortality, however, seems to be significantly higher when compared to a group of pT3M1LYM/pT4 patients who underwent primary surgery (8.3 versus 2.3%; P ¼ 0:015) in the same period in our department. q 2003 Elsevier Science B.V. All rights reserved.

Objective: Modern large single institutional reports on pulmonary sequestration (PS) are extremely rare. We were interested in comparing patients with PS referred by our pediatric versus adult pulmonologists. Methods: Hospital notes of all patients operated on between 1978 and 1997 for a congenital broncho-pulmonary malformation were reviewed. In 28 patients, the parenchymal lesion was vascularized by a systemic artery and was separated from the bronchial tree, thus matching the strict definition of PS. Patient characteristics and outcome were analyzed comparing the pediatric group (#16 years: na 13; mean age, 3 ^ 5 years) versus the adult group (.16 years: na 15; mean age, 33 ^ 13 years). Results: No significant differences between both groups were observed in sex, side, type of sequestration, pulmonary venous drainage, associated anomalies, hospital and late outcome, and patient’s overall score. Patients (na 21) with the intralobar type of sequestration presented significantly more often with an infection when compared with patients (na 7) with the extralobar type (91 versus 14%; Pa 0:0033). When compared with the pediatric group, patients in the adult group had significantly more respiratory infections (87 versus 38%; Pa 0:016), and also required a lobectomy more often (67 versus 31%; Pa 0:056). Conclusions: The extralobar type of sequestration often remains asymptomatic, and is usually an incidental finding during infancy. The intralobar type mostly presents with recurrent infections in adulthood resulting in more lobectomies. We believe these findings support our current policy to remove any pulmonary malformation whenever diagnosed in order to: (1), prevent infection and other potentially serious late complications which may compromise the surgical outcome; and (2), enhance the chance of a parenchymal-sparing resection. q 2001 Elsevier Science B.V. All rights reserved.

Objective: The results of primary surgery for non-small cell lung cancer (NSCLC) with involved ipsilateral mediastinal or subcarinal lymph nodes (N2 disease) remains poor. However, several studies suggest that induction chemotherapy could increase long-term survival in patients with N2 disease. Therefore, accurate preoperative staging of the mediastinum remains of paramount importance for the treatment policy in patients with NSCLC. Enlarged mediastinal lymph nodes (MLN) on CT scan are positive in only half of the patients. Small lymph nodes can contain metastatic deposits of clinical importance. However, many surgeons believe that a normal mediastinum at computed tomography allows them to cancel their preoperative mediastinal exploration. It was the aim of this study to evaluate the results of cervical mediastinoscopy in patients without enlarged MLN on CT scan. Methods: Between January 1990 and June 1994, 235 patients with potentially operable NSCLC underwent a cervical mediastinoscopy despite the absence of enlarged MLN on CT scan. MLN were considered enlarged if they were equal to or larger than 15 mm at their maximal cross-sectional diameter. Results: Cervical mediastinoscopy was positive in 47 patients (20%). In 21 patients, N2 disease was extranodal and in 16 patients more than one level was involved. Mediastinoscopy was positive in 9.5% of the cT1NO cases, in 17.7% of the cT2NO lesions, in 31.2 and 33.3% of cT3NO or cT4NO tumors, respectively. After a negative cervical mediastinoscopy, resectability for unforeseen N2 disease was as high as 95%. Conclusion: We recommend a cervical mediastinoscopy in every patient with potentially operable NSCLC. © 1997 Elsevier Science B.V.

Objective: Minimal invasive antireflux surgery is now a well accepted technique gaining a wide spread popularity. Simultaneously there is a growing tendency to fit all surgical candidates into one single type of operation, i.e. laparoscopic Nissen antireflux operation. This study evaluates the impact of this new technology on the strategy and practice of a major referral centre for antireflux surgery. Methods: An analysis was made of indications for the different types of antireflux techniques performed between July, 1993 and 1995. If on Barium swallow the gastro-oesophageal (GO) junction proved to be reducible, a laparoscopic approach was proposed, if not, an open transthoracic access was preferred. Results: One hundred and fifteen patients were operated. Fifty five patients underwent a minimal invasive approach: 49 Nissen (are the total fundoplication) and 3 Lind (are the partial fundoplication) operations through laparoscopy, 3 Belsey Mark IV through video assisted thoracic surgery (VATS). Sixty patients were treated by open surgery for following reasons: conversion to open surgery in 2 cases, redo surgery in 15 cases, previous other major abdominal surgery in 12, irreducible GO junction in 5, paraoesophageal or mixed type hernia in 12, Barrett and or oesophagitis IV in 4, combined antireflux surgery and feeding gastrostomy in 5, abdominal partial fundoplication by principle in 1, associated motility disorder in 1, combined reflux and gastric ulcer disease in 2, and severe emphysema in 1. In the laparoscopic series reflux control at 1 year post surgery as measured by 24 h pH study in 28 patients was obtained in 89.5%. One patient required a reoperation for symptomatic recurrence. Conclusions: (1) Laparoscopic antireflux surgery is a feasible and well accepted technique; (2) careful study of each individual patient is of paramount importance to choose the correct type of operation and access as well. Therefore, fitting every patient into a single type of operation, i.e. laparoscopic Nissen, should be avoided; (3) thoracic surgeons with a major interest in GO reflux disease should familiarize themselves with laparoscopic antireflux procedures. © 1997 Elsevier Science B.V.

Objective: The aim was to conduct a comparative analysis of outcome after minimally invasive oesophagectomy (MIO) versus open oesophagectomy (OO) for early oesophageal and gastro-oesophageal junction (GOJ) carcinoma. Methods: Inclusion criteria for MIO and a matched group of OO were pT < 2 and N0. Surgical outcome, complications, survival and health-related quality of life (HRQL) were assessed. Results: Between January 2005 and January 2010, 175 patients (101 OOs, 65 MIOs and nine MIOs converted to OO) fulfilled the abovementioned criteria. Histology was predominantly adenocarcinoma (75%), equally distributed between both groups as were preoperative co-morbidities ( p = 0.43), pathologic staging (pT: p = 0.56) and mean number of resected lymph nodes in pTIS/1a ( p = 0.23) and pT1b ( p = 0.13). Blood loss was less ( p = 0.01) and duration of operation longer ( p = 0.001) in MIO. Hospital mortality ( p = 0.66) and postoperative complications ( p = 0.34) were comparable. However, respiratory complications ( p = 0.008) and intensive care unit (ICU) admission ( p = 0.02) were higher in OO. Gastrointestinal complications ( p = 0.005), that is, gastroparesis ( p = 0.004) were more frequent in MIO. At 3 months, postoperative fatigue, pain (general) and gastrointestinal pain were less in MIO ( p = 0.09, 0.05 and 0.01, respectively). Five-year cancer-specific and recurrence-free survival stratified to the pathologic T-stage were not statistically different between MIO and OO. Conclusion: MIO is a valuable alternative to OO for the treatment of early oesophageal and GOJ carcinoma. This study underscores the need for large-scale, preferably multicentric studies to assess the real value of MIO versus OO. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective: Single-lung transplantation (SLTx) is a valid treatment option for patients with non-suppurative end-stage pulmonary disease. This strategy helps to overcome current organ shortage. Side is usually chosen based on pre-transplant quantitative perfusion scan, unless specific recipient considerations or contralateral lung offer dictates opposite side. It remains largely unknown whether outcome differs between left (L) versus right (R) SLTx. Methods: Between July 1991 and July 2009, 142 first SLTx (M/F = 87/55; age = 59 (29—69) years) were performed from 142 deceased donors (M/F = 81/61; age = 40 (14—66) years) with a median follow-up of 32 (0—202) months. Indications for SLTx were emphysema (55.6%), pulmonary fibrosis (36.6%), primary pulmonary hypertension (0.7%), and others (7.0%). Recipients of L-SLTx (n = 72) and R-SLTx (n = 70) were compared for donor and recipient characteristics and for early and late outcome. Results: Donors of L-SLTx were younger (37 (14—65) vs 43 (16—66) years; p = 0.033). R-SLTx recipients had more often emphysema (67.1% vs 44.4%; p = 0.046) and replacement of native lung with 50% perfusion (47.1% vs 23.6%; p = 0.003). The need for bypass, time to extubation, intensive care unit (ICU) and hospital stay, and 30-day mortality didnotdifferbetweengroups.Overallsurvivalat1,3,and5yearswas78.4%,60.5%,and49.4%,respectively, withamediansurvivalof60 months, with no significant differences between sides. Forced expiratory volume in 1 s (FEV1) improved (p < 0.01) in both groups to comparable values up to 36 months. Complications overall (44.4% vs 50.0%) or in allograft (25.0% vs 24.3.0%) as well as time to bronchiolitis obliterans syndrome (BOS) (35 months) and 5-year freedom from BOS (68.9% vs 75.0%) were comparable after L-SLTx versus R-SLTx, respectively. There were no differences in all causes of death (p = 0.766). On multivariate analysis, BOS was a strong negative predictor for survival (hazard ratio (HR) 6.78; p < 0.001), whereas side and mismatch for perfusion were not. Conclusion: The preferred side for SLTx differed between fibrotic versus emphysema recipients. Transplant side does not influence recipient survival, freedom from BOS, complications, or pulmonary function after SLTx. Besides surgicalconsiderationsintherecipient,offerofa donorlungoppositeto thepreferredsideshouldnotbea reasonto postpone thetransplantation until a better-matched donor is found. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.