Modifications, classification, and outcomes of elephant-trunk procedures.

BACKGROUND: There are a variety of modified elephant-trunk methods, including use of endovascular stents. Our objectives were to classify these modifications, compare outcomes between the classic anastomotic site and these alternatives, and investigate time to second-stage elephant-trunk completion. METHODS: From May 1992 to January 2011, 526 patients underwent a first-stage elephant-trunk procedure and were the subject of analysis. RESULTS: Distal aortic anastomosis was located before the brachiocephalic artery in 6 patients (1.1%), between brachiocephalic and left common carotid artery (LCCA) in 1 (0.19%), between LCCA and left subclavian artery (LSCA) in 154 (29%), and beyond the LSCA (classic) in 365 (69%). Stroke occurred in 8% (n = 42) overall, 10% (n = 16) in the LCCA-LSCA group, and 6.8% (n = 25) in the classic group. Risk factors were older age and acute dissection. Thirty-day mortality was 7.6% (n = 40) and was similar for LCCA-LSCA (9.7%) and classic sites (6.3%; p = 0.7); risk factors included older age, smaller body surface area, and end-organ dysfunction. Likelihood of death before second-stage elephant trunk at 1, 4, and 8 years after operation was 16%, 22%, and 27%, respectively. The larger the distal aorta, the more likely was second-stage completion (p < 0.0001); when greater than 6 cm, 80% had second-stage completion. CONCLUSIONS: The elephant-trunk operation is safe for a broad population, including when anastomotic sites are other than beyond the LSCA. Without second-stage completion, patient mortality increases markedly after 4 years.

Midterm results of David reimplantation in patients with connective tissue disorder.

BACKGROUND: Few series have examined follow-up risks of the David reimplantation operation in patients with connective tissue disorder. Hence, we assessed its midterm safety and effectiveness for Marfan syndrome and other connective tissue disorders, such as Ehlers-Danlos, Loeys-Dietz, and marfanoid syndromes. METHODS: Of 313 patients who underwent modified David reimplantation, 178 identified as having connective tissue disorders underwent operation from January 1, 1991, to December 31, 2010. These disorders included Marfan (84%), marfanoid (8.4%), Loeys-Dietz (5.6%), Ehlers-Danlos (1.1%), and other syndromes (1.1%). Concomitant procedures included mitral valve repair in 7.3% and an atrial fibrillation procedure in 3.4%. RESULTS: There were no operative or 30-day deaths. Complications included prolonged ventilation (3%), renal failure (3%), reoperation for bleeding (2.2%), and permanent stroke (0.56%). Eight-year survival was 94% and freedom from aortic valve reoperation at 6 years was 92%. Of the 7 aortic valve reoperations, 3 were attributable to endocarditis and 3 to technical failure. One reoperation was performed at another hospital, and the reason could not be determined. There were no late strokes or hemorrhagic events. At 4 years, approximately 70% of patients had no aortic valve regurgitation, and 18% were in grade 1+. CONCLUSIONS: Prophylactic root and valve preservation using David reimplantation is safe and provides excellent midterm effectiveness and low risk of late events except for endocarditis.

Outcome of patients who refuse transfusion after cardiac surgery: a natural experiment with severe blood conservation.

BACKGROUND: Jehovah's Witness patients (Witnesses) who undergo cardiac surgery provide a unique natural experiment in severe blood conservation because anemia, transfusion, erythropoietin, and antifibrinolytics have attendant risks. Our objective was to compare morbidity and long-term survival of Witnesses undergoing cardiac surgery with a similarly matched group of patients who received transfusions. METHODS: A total of 322 Witnesses and 87 453 non-Witnesses underwent cardiac surgery at our center from January 1, 1983, to January 1, 2011. All Witnesses prospectively refused blood transfusions. Among non-Witnesses, 38 467 did not receive blood transfusions and 48 986 did. We used propensity methods to match patient groups and parametric multiphase hazard methods to assess long-term survival. Our main outcome measures were postoperative morbidity complications, in-hospital mortality, and long-term survival. RESULTS: Witnesses had fewer acute complications and shorter length of stay than matched patients who received transfusions: myocardial infarction, 0.31% vs 2.8% (P = . 01); additional operation for bleeding, 3.7% vs 7.1% (P = . 03); prolonged ventilation, 6% vs 16% (P < . 001); intensive care unit length of stay (15th, 50th, and 85th percentiles), 24, 25, and 72 vs 24, 48, and 162 hours (P < . 001); and hospital length of stay (15th, 50th, and 85th percentiles), 5, 7, and 11 vs 6, 8, and 16 days (P < . 001). Witnesses had better 1-year survival (95%; 95% CI, 93%-96%; vs 89%; 95% CI, 87%-90%; P = . 007) but similar 20-year survival (34%; 95% CI, 31%-38%; vs 32% 95% CI, 28%-35%; P = . 90). CONCLUSIONS: Witnesses do not appear to be at increased risk for surgical complications or long-term mortality when comparisons are properly made by transfusion status. Thus, current extreme blood management strategies do not appear to place patients at heightened risk for reduced long-term survival.

Changes in left ventricular morphology and function after mitral valve surgery.

Degenerative mitral valve disease is the leading cause of mitral regurgitation in North America. Surgical intervention has hinged on the symptoms and ventricular changes that develop as compensatory ventricular remodeling occurs. In the present study, we sought to characterize the temporal response of left ventricular (LV) morphology and function to mitral valve surgery for degenerative disease and to identify the preoperative factors that influence reverse remodeling. From 1986 to 2007, 2,778 patients with isolated degenerative mitral valve disease underwent valve repair (n = 2,607 [94%]) or replacement (n = 171 [6%]) and had ≥1 postoperative transthoracic echocardiogram; 5,336 transthoracic echocardiograms were available for analysis. Multivariate longitudinal repeated-measures analysis was performed to identify the factors associated with reverse remodeling. The LV dimensions decreased in the first year after surgery (end-diastolic from 5.7 ± 0.80 to 4.9 ± 1.4 cm; end-systolic from 3.4 ± 0.71 to 3.1 ± 1.4 cm). The LV mass index decreased from 139 ± 44 to 112 ± 73 g/m(2). The reduction in LV hypertrophy was less pronounced in patients with greater preoperative left heart enlargement (p <0.0001) and a greater preoperative LV mass (p <0.0001). The postoperative LV ejection fraction initially decreased from 58 ± 7.0% to 53 ± 20%, increased slightly during the first postoperative year, and was negatively influenced by preoperative heart failure symptoms (p <0.0001) and a lower preoperative LV ejection fraction (p <0.0001). The risk-adjusted response of LV morphology and function to valve repair and replacement was similar (p >0.2). In conclusion, a positive response toward normalization of LV morphology and function after mitral valve surgery is greatest in the first year. The best response occurs when surgery is performed before left heart dilation, LV hypertrophy, or LV dysfunction develop.

Moderate tricuspid regurgitation with left-sided degenerative heart valve disease: to repair or not to repair?

BACKGROUND: Uncertainty about long-term effects of surgically unaddressed moderate (2+) secondary tricuspid valve (TV) regurgitation (TR) accompanying left-sided degenerative heart valve disease led us to identify reasons for and factors associated with TV repair, compare safety and clinical effectiveness of relieving TR, and identify factors associated with severe (3/4+) postoperative TR. METHODS: From 1997 to 2008, 1,724 patients with 2+ TR underwent 830 mitral, 703 aortic, and 191 double-valve procedures; 91 (5%) had concomitant TV repair. Logistic regression analysis was used to identify factors associated with TV repair and for propensity-matched comparison of safety (in-hospital morbidity, mortality) and effectiveness of TV repair (longitudinal echocardiographic assessment of postoperative TR and New York Heart Association class, TV intervention, survival). RESULTS: Factors associated with TV repair of 2+ TR included larger right ventricles and left ventricles (p<0.001), greater TV tethering height (p=0.0002), and prior concurrent mitral valve procedures (p≤0.004). In-hospital complications, subsequent TV interventions, and intermediate-term survival were similar for matched patients. The TV repair patients had less 3/4+ TR at discharge (7% versus 15%), sustained out to 3 years. No TV repair (p=0.05), female sex (p<0.0001), and mitral valve replacement (p=0.008) were associated with 3/4+ TR. CONCLUSIONS: A TV repair for moderate TR concomitant with surgery for degenerative left-sided heart valve disease is reasonable to provide an opportunity to prevent its progression and development of right ventricle dysfunction, particularly for patients with important right ventricle remodeling and evidence of right ventricular failure, and for patients with advanced left-sided disease requiring mitral valve replacement.

Reoperations after the ross procedure in adults: towards autograft-sparing/Ross reversal.

BACKGROUND AND AIM OF THE STUDY: The risk of reoperation and loss of a second native valve is a major drawback of the Ross operation. The study aim was to examine the indications, pathologies, procedures, and outcomes for reoperation after the Ross procedure, emphasizing the potential for autograft salvage. METHODS: Between 1994 and 2009, a total of 60 reoperations was performed on 55 patients who previously had undergone the Ross procedure. Attention was focused on 49 patients with first-time reoperation for autograft or allograft-related problems (37 males, 12 females; mean age 49 +/- 14 years). At the original operation, 23% of patients had a history of endocarditis, 14% a previous valve replacement, and 61% a bicuspid aortic valve. The original implant technique was full root in 88% of cases, inclusion root in 2%, or subcoronary implant in 9%. Autograft and aortic indications (n = 38) included root and ascending aorta dilatation (53%), structural valve cusp deterioration (32%), endocarditis (11%), and technical failure (5%). Regurgitation was moderate to severe in 97% of cases. Pulmonary indications (n = 21) were allograft degeneration (71%), endocarditis (10%), and Ross reversal (19%). The autograft and aorta reoperation procedures (n = 38) included ascending aorta replacement (n = 2), David reimplantation (n = 1), valve repair (n = 2), valve replacement (n = 13), and root replacement (n = 22). Pulmonary valve replacements (n = 21) were with pulmonary allograft in 12 cases and autograft (Ross reversal) in nine. Twelve of the pulmonary valve replacement group, including the Ross reversals, were combined aortic and pulmonary. During the last 13 reoperations, only two autografts were lost, both of which were potentially salvageable. RESULTS: No intraoperative adverse events or postoperative deaths occurred, and minimal morbidity was observed. During the follow up period there was one death, while two patients required reoperation (one for endocarditis and one non-valve-related). CONCLUSION: Reoperation at up to 12 years after a Ross procedure was most commonly required for autograft failure, and less often for allograft degeneration. Of reassurance to prospective Ross patient was the finding that reoperation can be performed safely, and that the autograft can be salvaged either by repair and valve-sparing reimplantation in the aortic position, or by Ross reversal.

Results of matching valve and root repair to aortic valve and root pathology.

OBJECTIVE: For patients with aortic root pathology and aortic valve regurgitation, aortic valve replacement is problematic because no durable bioprosthesis exists, and mechanical valves require lifetime anticoagulation. This study sought to assess outcomes of combined aortic valve and root repair, including comparison with matched bioprosthesis aortic valve replacement. METHODS: From November 1990 to January 2005, 366 patients underwent modified David reimplantation (n = 72), root remodeling (n = 72), or valve repair with sinotubular junction tailoring (n = 222). Active follow-up was 99% complete, with a mean of 5.6 ± 4.0 years (maximum 17 years); follow-up for vital status averaged 8.5 ± 3.6 years (maximum 19 years). Propensity-adjusted models were developed for fair comparison of outcomes. RESULTS: Thirty-day and 5-, 10-, and 15-year survivals were 98%, 86%, 74%, and 58%, respectively, similar to that of the US matched population and better than that after bioprosthesis aortic valve replacement. Propensity-score-adjusted survival was similar across procedures (P > .3). Freedom from reoperation at 30 days and 5 and 10 years was 99%, 92%, and 89%, respectively, and was similar across procedures (P > .3) after propensity-score adjustment. Patients with tricuspid aortic valves were more likely to be free of reoperation than those with bicuspid valves at 10 years (93% vs 77%, P = .002), equivalent to bioprosthesis aortic valve replacement and superior after 12 years. Bioprostheses increasingly deteriorated after 7 years, and hazard functions for reoperation crossed at 7 years. CONCLUSIONS: Valve preservation (rather than replacement) and matching root procedures have excellent early and long-term results, with increasing survival benefit at 7 years and fewer reoperations by 12 years. We recommend this procedure for experienced surgical teams.

Predictors of acute rejection after lung transplantation.

BACKGROUND: Acute rejection (AR) after lung transplantation (LTx) impacts survival and quality of life. The objective of this study, therefore, was to identify risk factors for AR after LTx, focusing on donor- and recipient-specific factors, operative variables, and immunologic issues, including pretransplant panel-reactive antibody (PRA) levels, and donor-recipient human leukocyte antigen (HLA) mismatch. METHODS: From March 1996 to November 2007, 481 adults undergoing LTx had 3237 serial transbronchial biopsy specimens that were evaluated for perivascular rejection (grade A0 to A4). Longitudinal analysis was used to characterize the prevalence of rejection grade and influence of donor, recipient, technical, and immunologic variables. RESULTS: AR was highest (54%≥A1) in the first 2 months after LTx, decreased at 6 months (16%≥A1), then remained steady. Prevalence of AR at any time was dominated by donor-specific factors of young age (p<0.0001), blunt trauma (p=0.008), and nonblack race (p=0.012) and by recipient class II PRA exceeding 10% (p=0.005). AR within 2 months was associated with HLA mismatch at the DR locus (p=0.0006) and use of non-O blood-group donors (p=0.008). AR at 4 years and longer after LTx was associated with HLA mismatch at the B locus (p=0.01). CONCLUSIONS: Only a few recipient and operative factors were identified for AR after LTx. Moderately sensitized recipients identified by class II PRA exceeding 10% and those with HLA mismatches at the B and DR loci appear to be more susceptible to AR; however, such immunologic variations appear to be well controlled with current donor selection and immunosuppression protocols. The impact of donor-specific variables on AR is surprisingly strong and warrants closer inspection.

Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting.

CONTEXT: Stroke is a devastating and potentially preventable complication of coronary artery bypass graft (CABG) surgery. Better understanding of the timing and risk factors for stroke associated with CABG are needed. OBJECTIVES: To investigate temporal trends in stroke after CABG and to identify stroke risk factors and association with longitudinal outcomes. DESIGN, SETTING, AND PATIENTS: Prospective study conducted from 1982 through 2009 at a single US academic medical center among 45,432 consecutive patients (mean age, 63 [SD, 10] years) undergoing isolated primary or reoperative CABG surgery. Strokes occurring following CABG were recorded prospectively and classified as having occurred intraoperatively or postoperatively. Complications and survival after stroke were assessed in propensity-matched groups. INTERVENTION: CABG performed using 4 different operative strategies (off-pump, on-pump with beating heart, on-pump with arrested heart, on-pump with hypothermic circulatory arrest). MAIN OUTCOME MEASURES: Hospital complications; late survival. RESULTS: Among 45,432 patients undergoing CABG surgery, 705 (1.6% [95% confidence interval {CI}, 1.4%-1.7%]) experienced a stroke. The prevalence of stroke peaked in 1988 at 2.6% (95% CI, 1.9%-3.4%), then declined at 4.69% (95% CI, 4.68%-4.70%) per year (P = .04), despite increasing patient comorbidity. Overall, 279 strokes (40%) occurred intraoperatively and 409 (58%) occurred postoperatively (timing indeterminate in 17 patients). Postoperative stroke peaked at 40 hours, decreasing to 0.055%/d (95% CI, 0.047%-0.065%) by day 6. Risk factors for both intraoperative and postoperative stroke included older age (odds ratio, 8.5 [95% CI, 3.2-22]) and variables representing arteriosclerotic burden. Intraoperative stroke rates were lowest in off-pump CABG (0.14% [95% CI, 0.029%-0.40%]) and on-pump beating-heart CABG (0% [95% CI, 0%-1.6%]), intermediate with on-pump arrested-heart CABG (0.50% [95% CI, 0.41%-0.61%]), and highest with on-pump CABG with hypothermic circulatory arrest (5.3% [95% CI, 2.0%-11%]). Patients with stroke had worse adjusted hospital outcomes, longer intensive care and postoperative stays, and worse downstream survival (mean, 11 [SD, 8.6] years). CONCLUSION: Among patients undergoing CABG surgery at a single center over the past 30 years, the occurrence of stroke declined despite an increasing patient risk profile, and more than half of strokes occurred postoperatively rather than intraoperatively.

Winning the battle, losing the war: the noncurative "curative" resection for stage I adenocarcinoma of the lung.

BACKGROUND: Understanding recurrence of surgically "cured" stage I adenocarcinoma of the lung is important given expected benefits of adjuvant therapy for advanced disease. Therefore, this study characterizes cancer recurrence and its risks, assesses survival after recurrence, and contextualizes overall survival and its risks. METHODS: From 1991 to 2001, 285 patients underwent resection of stage I adenocarcinoma (pathologic) of the lung. They were followed cross-sectionally for evidence of cancer recurrence (mean follow-up 7.7 ± 4.3 years). Risk factors for recurrence and all-cause mortality were sought among demographic, medical history, cancer pathology, and surgical procedure data. RESULTS: Cancer recurred in 99 patients. Freedom from recurrence was 92%, 72%, and 57% at 1, 5, and 10 years. Two phases of risk were found: an early hazard phase and an essentially constant late phase after 5 years, with recurrences equally distributed. Early recurrence was associated with larger tumor size in patients who did not undergo mediastinal lymphadenectomy (p = 0.004). Late recurrence was more common in patients with higher pack-years of smoking (p = 0.007). Survival after recurrence was 40% and 17% at 1 and 5 years. Overall survival (65% and 40% at 5 and 10 years) depended not only on variables related to cancer recurrence, but also those of vitality (older age, pulmonary dysfunction, postpneumonectomy state). CONCLUSIONS: Stage I adenocarcinoma of the lung recurs. Identifying high-risk patients will simplify decision making for adjuvant therapy and surveillance. Thorough mediastinal lymphadenectomy dissociates tumor size as a predictor of survival and may itself provide an important survival benefit.

Simplified david reimplantation with reduction of anular size and creation of artificial sinuses.

BACKGROUND: The David reimplantation procedure is the preferred method of preserving tricuspid aortic valves during aortic root replacement. We report the results of a simplified approach to the David valve-sparing root reimplantation. METHODS: Of 234 patients who underwent David reimplantation or some modification thereof, 129 operated on from January 2001 to June 2008 formed a consecutive single-surgeon series for midterm evaluation. Aortic anulus-left ventricular outflow tract and proximal tube graft size were reduced over a Hegar dilator to mean normal diameter based on body surface area, in the process creating neo-sinuses to accommodate cusp opening. Sixty-one patients (47%) had Marfan syndrome. Mean body surface area was 2.1 +/- 0.27 m(2). Preoperative aortic regurgitation grade was 1+ or less in 46%, 2+ in 26%, 3+ in 24%, and 4+ in 4.3%. RESULTS: Left ventricular outflow tract sizing by Hegar dilator was 17 mm in 9.5% of patients, 19 mm in 18%, 21 mm in 56%, and 23 mm in 16%. Fifty-five (43%) had concomitant cusp repair. Postoperative aortic regurgitation grade was 0 in 98%, and none of the remaining had greater than 2+ AR. Postoperative mean aortic gradient was 9.0 +/- 3.5 mm Hg. No patient had intraoperative abandonment of the repair, and there were no postoperative deaths or strokes. Five-year survival was 99%, and 4 patients (3%) required late valve replacement. CONCLUSIONS: A simple modification of the David operation, reducing anular size, and creating neo-sinuses preserves the aortic valve, eliminates aortic regurgitation, avoids aortic stenosis, and has favorable midterm results.

Prevalence and repair of intraoperatively diagnosed patent foramen ovale and association with perioperative outcomes and long-term survival.

CONTEXT: A recent survey suggested that cardiothoracic surgeons may alter planned procedures to repair incidentally discovered patent foramen ovale (PFO). How frequently this occurs and the impact on outcomes remain unknown. OBJECTIVE: To measure the frequency of incidentally discovered PFO closure during cardiothoracic surgery and determine its perioperative and long-term impact. DESIGN, SETTING, AND PATIENTS: We reviewed the intraoperative transesophageal echocardiograms of 13,092 patients without prior diagnosis of PFO or atrial septal defect undergoing surgery at the Cleveland Clinic, Cleveland, Ohio, from 1995 through 2006. Postoperative outcomes were prospectively collected until discharge. MAIN OUTCOME MEASURES: All-cause hospital mortality and stroke were predetermined primary outcomes; length of hospital stay, length of intensive care unit stay, and time on cardiopulmonary bypass were secondary outcomes. RESULTS: Intraoperative PFO was diagnosed in 2277 patients in the study population (17%), and risk factors for stroke were similar in patients with and without PFO. After propensity matching was performed with the comparator groups, patients with PFO demonstrated similar rates of in-hospital death (3.4% vs 2.6%, P = .11) and postoperative stroke (2.3% vs 2.3%, P = .84). Surgical closure was performed in 639 PFO patients (28%), and surgeons were more likely to close defects in patients who were younger (mean [SD] age, 61.1 [14] vs 64.4 [13] years; P < .001), were undergoing mitral or tricuspid valve surgery (51% vs 32%, P < .001), or had history of transient ischemic attack or stroke (16% vs 10%, P < .001). Patients with repaired PFO demonstrated a 2.47-times greater odds (95% confidence interval, 1.02-6.00) of having a postoperative stroke compared with those with unrepaired PFO (2.8% vs 1.2%, P = .04). Long-term analysis demonstrated that PFO repair was associated with no survival difference (P = .12). CONCLUSIONS: Incidental PFO is common in patients undergoing cardiothoracic surgery but is not associated with increased perioperative morbidity or mortality. Surgical closure appears unrelated to long-term survival and may increase postoperative stroke risk.

Temporal pattern of transfusion and its relation to rejection after lung transplantation.

BACKGROUND: Blood transfusion has been shown to impact rejection after renal and cardiac transplantation, but it has not been studied after lung transplantation (LTx). In this study we assess: (1) patterns of transfusion, and (2) temporal interrelationships with histologic evidence of rejection. METHODS: From July 1998 to January 2006, 326 of 331 patients undergoing LTx had available for study both time-related post-operative blood transfusion data and their series of transbronchial biopsy evaluations of perivascular rejection grade (Grades A0 to A4). Longitudinal temporal decomposition for ordinal variables was used to characterize prevalence of rejection grade and simultaneously assess the influence of (a) red blood cell (RBC), (b) platelet and (c) plasma administration. RESULTS: Although peri-operative transfusion was common, transfusions continued at a low, steady rate throughout the life of LTx patients; patients received a total of 2,841 RBC units through follow-up. Immediately after LTx, the prevalence of Grade A0 rejection was 51%, and this increased to 84% by 6 months. RBC transfusion between biopsies was associated with lower histologic grade of rejection (70%, 73% and 77% with Grade A0 for 0, 1 and 12 units, respectively; p = 0.009), and this was particularly evident early after LTx. Histologic grade was not influenced by platelets or plasma. CONCLUSIONS: Transfusion requirements are high and continue throughout life after LTx; causes and effective treatment of persistent anemia should be sought. RBC transfusion appears to have an immunosuppressive effect, particularly early after transplant.

Matching donor to recipient in lung transplantation: How much does size matter?

OBJECTIVE: The impact of size matching between donor and recipient is unclear in lung transplantation. Therefore, we determined the relation of donor lung size to 1) posttransplant survival and 2) pulmonary function as measured by forced expiratory volume in 1 second. METHODS: From 1990 to 2006, 469 adults underwent lung transplantation with lungs from donors aged 7 to 70 years. Donor and recipient total lung capacities were calculated using established formulae (predicted total lung capacity), and actual recipient lung size was measured in the pulmonary function laboratory. Disparity between donor and recipient lung size was expressed as a ratio of donor predicted total lung capacity to recipient predicted total lung capacity-the predicted total lung capacity ratio-and predicted donor total lung capacity to actual recipient total lung capacity-the actual total lung capacity ratio. Survival was measured by multiphase hazard methodology and repeated measures of National Health and Nutrition Examination Survey-normalized forced expiratory volume in 1 second analyzed by temporal decomposition. RESULTS: Predicted total lung capacity ratio and actual total lung capacity ratio ranged widely, from 0.55 to 1.59 and 0.52 to 4.20, respectively. Overall survival was unaffected by predicted total lung capacity ratio (P = .3) or actual total lung capacity ratio (P = .5). Patients with emphysema and an actual total lung capacity ratio of 0.67 or less or 1.03 or greater had higher predicted mortality (P = .01). During the first posttransplant year, forced expiratory volume in 1 second increased and then gradually declined. Predicted total lung capacity ratio and actual total lung capacity ratio had a small impact on forced expiratory volume in 1 second, primarily in the late phase after transplant in a disease-specific manner. CONCLUSION: Size matching between donor and recipient using predicted total lung capacity ratio and actual total lung capacity ratio is an effective technique. Wide discrepancies in lung sizing do not affect overall posttransplant survival or pulmonary function. Therefore, a greater degree of lung size mismatch can likely be accepted, thereby improving patients' odds of undergoing transplantation.