THORAXHEELKUNDE - UZ Leuven

THORAXHEELKUNDEARTS J., LERUT T., RUTGEERTS P., SIFRIM D., JANSSENSJ., TACK J.: A one-year follow-up study of endoluminalgastroplication (Endocinch) in GERD patients refractory toproton pump inhibitor therapy. Dig. Dis. Sci., 2005; 50(2):351-356.In a subset of patients with gastroesophageal refluxdisease (GERD), symptoms persist in spite of protonpump inhibitor (PPI) therapy. Endoscopic gastroplication(EG) was reported to provide a novel therapeutic optionin GERD. To evaluate symptomatic and objectiveoutcome of EG in PPI refractory GERD, consecutiveGERD patients with persisting reflux symptoms during atleast 2 months double dose PPI were recruited for EG(Endocinch). Exclusion criteria were high-gradeesophagitis, Barrett's esophagus, and hiatal hernia > 3cm. Symptoms and PPI use were evaluated before and1, 3, and 12 months after the EG; 24-hr pH monitoringoff PPI was performed before and after 3 and 12 months.All data are given as mean +/- SD and were analyzed byStudent's t test. Twenty patients (10 females; mean age,45 +/- 11 years) were recruited. Under conscioussedation with midazolam (6 +/- 2 mg) and pethidine (53+/- 5 mg), a mean of 2.0 +/- 0.2 sutures was appliedduring a procedure time of 33 +/- 6 min. Throat ache andmild epigastric pain for up to 3 days after the procedurewere the only adverse events. At 3 and 12 monthssymptom score (11.6 +/- 6 vs. 6.4 +/- 3.7 [P < 0.01] and7.1 +/- 4.5 [P < 0.05]) as well as pH monitoring (% timepH < 4: 17.0 +/- 11.1 vs. 8.1 +/- 5.7% [P < 0.01] and 9.8+/- 4.1% [P < 0.01]) significantly improved. Ph monitoringwas normalized (< 4% of time) in seven patients after 3months. PPIs could be stopped in 13 patients, with 2patients still using H2-blockers and 1 using cisaprideafter 3 months. After 12 months only six patients werefree of PPI use and pH monitoring was normalized in sixpatients. We conclude that EG provides short- andmedium-term symptomatic and objective relief to asubset of GERD patients refractory to high-dose PPI.

CHRISTIE J.D., VAN RAEMDONCK D., DE PERROT M.,BARR M., KESHAVJEE S., ARCASOY S., ORENS J. and theworking group on primary lung graft dysfunction: Report of theISHLT working group on primary lung graft dysfunction.Part I: Introduction and methods. J. Heart Lung Transplant,2005; 24(10): 1451-1453.Primary graft dysfunction is a form of acute lung injurythat follows the sequence of events inherent in the lungtransplantation process, beginning with the brain deathof the donor, pulmonary ischemia, preservation of donortissue, transplantation, and reperfusion of donor tissue inthe recipient. Despite numerous recent advances inorgan preservation, surgical technique and perioperativecare, post-transplant allograft dysfunction issufficiently common to warrant the use of a wide rangeof synonyms. These include ischemia–reperfusion injury,re-implantation response, re-implantation edema,reperfusion edema, non-cardiogenic pulmonary edema,early graft dysfunction, primary graft dysfunction (PGD),primary graft failure (PGF) and post-transplant acuterespiratory distress syndrome (ARDS) or acute lunginjury (ALI). The expressions used to describe thiscondition are not perfectly synonymous, with somerepresenting the most severe end of the spectrum oflung allograft ischemia–reperfusion injury and othersrepresenting less severe clinical syndromes. Despitevariation in studies, it is clear that PGD is responsible forsignificant morbidity and mortality after lungtransplantation. Furthermore, with efforts in place toexpand the donor pool, the expectation is that efforts totreat and/or prevent PGD will remain important to thefield of lung transplantation. The International Society ofHeart and Lung Transplantation (ISHLT) Working Groupon Primary Lung Graft Dysfunction was formed at thesuggestion of the ISHLT Pulmonary Council in 2003. Thepurpose of this group was to review the availableliterature to provide a state-of-the-art, comprehensiveseries of documents to serve as a resource for cliniciansand researchers. In addition, a major goal was tostandardize consensus-defining criteria to facilitate futurestudies of PGD.DEKETELAERE A., KELCHTERMANS G., STRUYF E., DELEYN P.: Een beter begrip van ervaringsleren tijdens destage (co-assistentschap) in het derde jaar van deartsopleiding. TMO, 2005; 24(1): 46-47.De kwaliteit van de leerervaringen tijdens deverschillende stagemomenten wisselt sterk. Dikwijls is ereen groot accent op werken, ten koste van leren. Alstheoretisch referentiekader werd gebruik gemaakt vanhet concept ‘Breed en Diep Ervaringsleren’, ontwikkeldbinnen de Lerarenopleiding. Dit concept maakt eenonderscheid tussen vorm en inhoud: naar vorm betekentervaringsleren het expliciet terugblikken op ervaringen

om er leerinzichten en conclusies uit te trekken voortoekomstig handelen. Naar inhoud houdt breedervaringsleren in dat de reflecties niet alleen detechnische aspecten, maar ook de more, ethische enpolitieke dimensies van de ervaring betreffen. Diepervaringsleren betekent dat er ook stil gestaan wordt bijde achterliggende opvattingen die aan de basis liggenvan het handelen. Diep ervaringsleren heeft dus nietalleen een grotere effectiviteit van handelen maar ookeen grotere geldigheid van de denkkaders tot gevolg.DEKETELAERE A., KELCHTERMANS G., STRUYF E., DELEYN P.: Spanningsvelden in de klinische leeromgeving.Een exploratieve studie van stage-ervaringen. TMO, 2005;24(3): 103-112.Probleemstelling: De stage (het co-assistentschap) iseen essentieel onderdeel van de opleiding tot arts, maarniet alle stages leiden tot de verhoopte leerresultaten. Indit artikel rapporteren we over een exploratief onderzoeknaar de determinanten van de stage-ervaringen.Uitgangspunt is de idee dat die ervaring in belangrijkemate bepaald wordt door de betekenisvolle interactietussen stagiair en stage-omgeving (in het bijzonder destageleiders).Onderzoeksopzet en methodologie: Door middel vaninterpretatieve methodieken (student shadowing,interviews) werden gegevens verzameld bij achtstagiairs en hun stageleiders in twee perifereziekenhuizen. De interpretatieve analyse van degegevens werd ter validering voorgelegd aanfocusgroepen van stagiairs en stageleiders.Resultaten: De analyse resulteerde in het identificerenvan vijf componenten die toelaten de stage-ervaringen inkaart te brengen en te begrijpen. Elke component blijktbeschreven te kunnen worden in termen van eenspanningsveld. Deze componenten zijn: 1) de stageagenda(werken versus leren), 2) de begeleidershouding(evaluator versus coach), 3) de stage-cultuur(beroepsgericht versus opleidingsgericht), 4) deleerhouding van de stagiair (receptief versus pro-actief),5) de aard van het leerproces (informeel versus formeel).De spanningsvelden in de respectievelijke componentendienen niet gezien te worden als op te lossentegenstellingen, maar zijn als zodanig constitutief voorde stage-ervaring. De stagiairs bevinden zichonvermijdelijk en voortdurend in de dynamiek van diespanningsvelden en dit bepaalt de impact van de stage.Relevantie en besluit: De componenten enspanningsvelden vormen een conceptueel kader dattoelaat de stage-ervaringen systematischer in kaart tebrengen en te analyseren. Voor de stagiairs helpt het omde ervaringen te duiden en het eigen leren te sturen.Aan stageleiders en opleidingsverantwoordelijken biedthet een begrippenkader om analytisch meer inzicht teverwerven in de betekenis van stage-ervaringen en omde kwaliteit van stageplaatsen als klinischeleeromgeving te evalueren.

DE LEYN P., LISMONDE M., NINANE V., NOPPEN M.,SLABBYNCK H., VAN MEERHAEGHE A., VAN SCHIL P.,VERMASSEN F.: Belgian Society of Pneumology.Guidelines on the management of spontaneouspneumothorax. Acta Chir. Belg., 2005; 105: 265-267.DEPREST J., JANI J., GRATACOS E., VANDECRUYS H.,NAULAERS G., DELGADO J., GREENOUGH A.,NICOLAIDES K. and the FETO Tast Group (VANSCHOUBROECK D., VANDEVELDE M., DEVLIEGER H.,CANNIE M., DYMARKOWSKI S., LERUT T., CARRERAS E.,SALCEDO S., TORAN N., PEIRO J.L., MARTINEZ-IBANEZ V.,COCKELL A., PATEL S., DAVENPORT M.: Fetal interventionfor congenital diaphragmatic hernia: The EuropeanExperience. Semin. Perinatol., 2005; 29(2): 94-103.Fetuses with CDH presenting with liver herniation and alung area-to-head circumference ratio of less than 1.0have a high chance for neonatal death due to pulmonaryhypoplasia. Fetal tracheal occlusion (TO) preventsegress of lung liquid, which triggers lung growth. Inanimal experiments, we were able to develop aminimally invasive technique for Fetoscopic EndoluminalTracheal Occlusion (FETO) with a detachable balloon. In2001, we demonstrated feasibility of FETO bypercutaneous access in fetuses with severe CDH. In aretrospective multicenter review, we obtained LHRmeasurements and position of the liver in 134 cases ofisolated left-sided CDH between 24 and 28 weeks.Eleven patients (8%) with LHR < 1.4 opted fortermination. Overall survival of liveborn babies was 47%(58/123). LHR and position of the liver correlated both tosurvival. Combination of both variables predictedneonatal outcome better: liver up and LHR < 1.0predicted a survival of 9%. When LHR < 0.6, there wereno survivors irrespective of liver position. We couldsuccessfully perform endotracheal placement of theballoon in 20 cases at a median gestational age of 26weeks. The mean duration of the operation was 22(range 5-54) minutes. In 11 (55%) of these patients,there was postoperative prelabor (ie,

died in the neonatal period due to complications of theunderlying disease. Two nonsurvivors died from othercauses but with appropriately developed lungs. Improvedsurvival coincided with increasing experience, in turnrelated to reduced incidence of postoperativeamniorrhexis, later delivery, and a change in the policyon the timing of removal of the balloon from intrapartumto the prenatal period. Survival in eligible contemporarycontrols was 1/12 (8%). The presence of liver herniationand a low lung-to-head ratio (LHR

Case presentation: We report an infant with bronchitisobliterans that was treated conservatively. 5 years afterthe initial event, partial lung re-expansion wasdocumented.Conclusion: This case therefore supports a conservativetreatment whenever possible with pneumonectomy onlyas a last treatment option.LERUT T., CEULEMANS P., COOSEMANS W., DECKER G.,DE LEYN P., NAFTEUX P., VAN RAEMDONCK D.,DEJAEGER E.: De divertikel van Zenker. Tijdschr. voorGeneeskunde, 2005; 61(6): 464-476.De divertikel van Zenker is een aandoening dievoornamelijk voorkomt in de geriatrische leeftijdsgroep.De symptomatologie behelst zowel de slokdarm als deluchtwegen en kan levensbedreigend zijn, zeker inaanwezigheid van belangrijke comorbiditeit.Hierbij moet men steeds bedacht zijn op de regelmatigvoorkomende associatie met gastro-oesofagale reflux.De behandeling van de divertikel van Zenker kangebeuren op verschillende manieren: via een opentoegangsweg onder vorm van extramuceuze myotomievan de m. cricopharyngeus en de proximale gestreepteslokdarmspier gecombineerd met een resectie van dedivertikel of een ophanging (diverticulopexie), of via eenendoscopische weg onder vorm van cauterisatie of CO 2lasering van de zogenaamde “cricofaryngale baar” ofeen “staple”-oesofagodiverticulostomie.Deze diverse methoden kunnen heden ten dage op eenveilige manier met een zeer laag mortaliteitsrisicoworden uitgevoerd. De morbiditeit is over het algemeenlaag met een korte hospitalisatieduur als resultaat.Het komt er bijgevolg op neer, mede het gegeven vaneen geriatrische populatie in acht nemend, om debehandelingsmethode te kiezen die het beste uitzichtbiedt op een definitief resultaat waarbij de patiëntvolledig klachtenvrij is. De open extramuceuze myotomieen de diverticulopexie lijken hiertoe de beste waarborgente bieden.LERUT T., COOSEMANS W., DECKER G., DE LEYN P.,MOONS J., NAFTEUX P.: VAN RAEMDONCK D.: SurgicalTechniques. J. Surg. Oncol., 2005. 92(3): 218-229.Adenocarcinoma of the esophagus andgastroesophageal junction (GEJ) has shown aremarkable increase during recent decades. Mostpatients are present with advanced stage disease,reflecting transmural growth and metastasis to lymphnodes at the time of diagnosis. Moreover, the pattern oflymph node dissemination is chaotic and difficult topredict, and despite the use of modern technology (e.g.,spiral CT, EUS, FDG-PET), clinical staging remainssuboptimal. These shortcomings in staging, as well as indifferent attitudes toward extent of resection and

lymphadenectomy, are reflected by a great variation insurgical techniques, which are discussed in this review.As to the results, primary surgery can currently beperformed with low mortality, below 5% in high volumecenters. Hospital mortality and morbidity are mainlyrelated to pulmonary complications and anastomoticleaks, the latter mostly resolving under conservativetreatment. Overall 5-year survival varies between 10%and 59%. As expected the most important prognosticdeterminants are completeness of resection (R0 vs. R1-R2) and lymph node status (N0, N1). R0 resectioncurrently offers 5-year survival rates of over 40%. Fiveyearsurvival figures for node-negative (N0) patientsexceed 70%, and even for node-positive (N1), patientsreach 25%. It is not known whether performing a threefieldlymph node dissection is beneficial for patients withadenocarcinoma of the distal esophagus. With overall 5-year survival currently exceeding 30%-40%, thesefigures should be the gold standard against which allother therapeutic modalities are compared.LERUT T., NAFTEUX Ph., MOONS J., COOSEMANS W.,DECKER G., DE LEYN P., VAN RAEMDONCK D.: Quality inthe surgical treatment of cancer of the esophagus andgastroesophageal junction. Eur. J. Surg. Oncol., 2005; 31:587-594.Surgical treatment of cancer of the esophagus andgastroesophageal junction (GEJ) remains a complex andchallenging task. Quality of care may be improved byconcentrating these patients in high volume centres inorder to decrease post-operative mortality. However, itappears that hospital mortality is a poor tool to measurethe quality. More likely specialisation as well asappropriate hospital environment supporting a dedicatedmultidisciplinary team are key elements in improvingboth the short term and long term results. The dedicatedspecialist surgeon has a key role in improving theseresults through surgical quality. The most important goalin the surgical treatment of these cancers is to perform acomplete resection (R0). Data from literature seem toindicate that R0 resection combined with extensivelymphadenectomy are resulting in improved disease freesurvival and possibly in improved 5 year survival, oftenreported to exceed 35% after such interventions. Theseresults suggest that there is a great need forstandardisation of surgery. Such a standardisation andthe resulting improved quality most likely will result in asignificant improvement of outcome of esophagectomyfor cancer of the esophagus and GEJ. Theseimprovements in outcome should become the goldstandard to which all other therapeutic regimens shouldbe compared. Poor surgical quality and related poorresults should not be a justification for multimodalityregimen.

LERUT T., STAMENKOVIC S., NAFTEUX P., COOSEMANSW., DECKER G., DE LEYN P., MOONS J., VANRAEMDONCK D.: Oesophageal cancer and cancer of thecardia. Staging: the role of endosonography, CT/MRI andPET. In: Gl Oncology and Innovative Aspects inGastroenterology. Eds.: R. Arnold, P. Malfertheiner, D.J.Gouma, John Libbey Eurotext, Paris, 2005: pp.33-37.The vast majority of invasive esophageal tumours aredetected by endoscopy or by a contrast study.Endoscopy with biopsy is required in all patients forhistological confirmation. Vital staining using Lugol orToluidin blue may be helpful to guide biopsy in cases ofearly carcinoma thus increasing diagnostic accuracy.Barium swallow will usually show an irregularly linedesophageal wall and is helpful mainly for topographicassessment of tumour extension and its relationship tothe carina, as this may have therapeutic implicationsconcerning the surgical access route.SCHILDERMANS R., VANSTEENKISTE J., DE LEYN P.,LIEVENS Y., NACKAERTS K., DOOMS C., VANRAEMDONCK D., namens de Leuven Lung Cancer Group.Multimodale behandeling bij vroegtijdige stadia van nietkleincelliglongcarcinoom: heden of toekomst. Tijdschr.voor Geneeskunde, 2005; 61(10): 783-790.Het niet-kleincellige longcarcinoom (NKCLC) komt veelvoor. Slechts 20 tot 30% van de patiënten komt primairin aanmerking voor radicale chirurgie, maar zelfs hiervanis slechts 40 tot 50% nog in leven na 5 jaar. Er werd nietaangetoond dat adjuvante radiotherapie de overlevingvan deze patiënten verbetert. Talrijke recente grotestudies wijzen wel op het nut van adjuvante, opcisplatine gebaseerde chemotherapie. Beperktegegevens suggereren ook een voordeel wanneerdezelfde chemotherapie preoperatief of neoadjuvantwordt gegeven.Dit artikel omvat een beschrijving van de historische enmeer recente gegevens betreffende adjuvante en neoadjuvante therapie bij vroegtijdige stadia van NKCLC, ende implicatie hiervan op de huidige dagdagelijksepraktijk.TILANUS H.W., KOPPERT L.B., LERUT L.T.:Oesophaguscarcinoom. In: Oncology. Editors: Tilanus H.W.,Kopper L.B., Lerut L.T., 2005, 7de herziene druk: 275-280.Wereldwijd stijgt de incidentie van het adenocarcinoomvan de (Barrett-) oesophagus, bij een gelijkblijvendeincidentie van het plaveiselcelcarcinoom. De diagnosewordt eenvoudig gesteld door oesofagoscopie en eenbiopsie, waarna op niet-invasieve wijze metendoscopische ultrasonografie, computertomografie enuitwendige echografie de prognose goed kan wordenbepaald en een behandelplan kan worden opgesteld.

Een op curatie gerichte behandeling bestaat uitoperatieve resectie, eventueel gecombineerd met neoadjuvantetherapie. Een zelfontplooibare stent ofbrachytherapie is op dit moment in Nederland de meestgebruikte palliatieve behandeling. Gezien de diversiteitaan diagnostische mogelijkheden en het grote aantal,deels curatieve en deels palliatieve, behandelingsoptiesmoet iedere patient met een oesophagocarcinoomworden behandeld door een multidisciplinair team vanspecialisten, zodat een optimaal behandelingsplan kanworden opgesteld.VAN RAEMDONCK D., KLEPETKO W., VERLEDEN G.M.,DAENEN W., COOSEMANS W., DECKER G., DE LEYN P.,NAFTEUX P., LERUT T.: Surgical aspects of (cardio)pulmonary transplantation. Rev. Mal. Respir., 2005; 22(5):785-795.Introduction and state of the art: Both short and longtermoutcomes following lung transplantation haveimproved substantially in recent years as a result ofadvances in the selection and management of donors,organ preservation, immunosuppressive therapy, andthe treatment of infectious and malignant complications.In addition surgical techniques have evolved over timeand have contributed to this increase in success rates.Perspectives and conclusions: This review outlinessurgical aspects of lung transplantation including ahistorical note, techniques of lung harvesting, someanaesthetic considerations, the different transplant typesand incisions, as well as anastomotic techniques andtheir pitfalls.VERLEDEN G.M., DUPONT L.J., VANHAECKE J., DAENENW., VAN RAEMDONCK D.E.M.: Effect of Azithromycin onbronchiectasis and pulmonary function in a heart-lungtransplant patient with severe chronic allograftdysfunction: a case report. J. Heart Lung Transplant, 2005;24: 1155-1158.Azithromycin has been shown to be beneficial in severaldiseases with chronic neutrophilic inflammation of theairways, such as cystic fibrosis and bronchiolitisobliterans syndrome (BOS) after lung transplantation. Upto now, however, its healing effect on bronchiectasis hasnever been demonstrated. We report a heart-lungtransplant patient who developed chronic rejection (BOSstage 3) with the appearance of gross bronchiectasis ona spiral computed tomography (CT) chest scan. Within 2weeks after starting azithromycin, the patient's forcedexpiratory volume in 1 second increased significantlyand a repeat spiral CT chest scan 5 months later,showed a major improvement of the bronchiectasis. Thiscase report illustrates that bronchiectasis may greatlyimprove after treatment with azithromycin and no longer

needs to be considered an endstage finding in patientswith severe BOS.VERLEDEN G.M., DUPONT L.J., VAN RAEMDONCK D.E.M.:Bronchiolitis obliterans syndrome after lungtransplantation. Minerva Pneumol., 2005; 44: 123-133Lung and heart-lung transplantation are currentlyrecognized as effective treatment modalities for selectedpatients with end-stage lung or heart-lung disease.Although the survival rates have improved in recentyears, long-term survival remains inferior compared toother solid organ transplantations, such as kidney, heartand liver. The main reason is the development of chronicrejection, which histologically manifests as obliterativebronchiolitis (OB), a process that leads to airwaysobstruction, with a gradual decline in pulmonary functiontests. Because of the difficulties in obtaining goodpathological specimens, a clinical grading system, calledbronchiolitis obliterans syndrome (BOS) has beenintroduced, divided into 4 and, more recently, 5categories, depending on the severity of airflowobstruction. Extensive research efforts have attemptedto unravel the pathophysiology of OB and identify keyprocess; Once established, the response to treatment isvery poor, although recently treatment withazithromycine, a neomacrolide antibiotic with extensiveanti-inflammatory effects, has proven to be effective in atleast some of these patients. This paper intends toreview the current knowledge of BOS and OB afterheart-lung and lung transplantation.VERLEDEN G.M., DUPONT L.J., VAN RAEMDONCK D.E.: Isit bronchiolitis obliterans syndrome or is it chronicrejection : a reappraisal? Eur. Respir. J., 2005; 25(2): 221-224.Chronic rejection (obliterative bronchiolitis) is the singlemost important cause of chronic allograft dysfunctionand late mortality after lung transplantation. As thiscondition is difficult to prove using biopsy specimens, aclinical term, bronchiolitis obliterans syndrome (BOS)has been in use for >10 yrs to describe the progressivedecrease of pulmonary function. However, beforediagnosing a patient as having BOS, based on asustained and progressive decrease in forced expiratoryvolume in one second and/or forced mid-expiratory flowbetween 25-75% of forced vital capacity, differentconfounding factors have to be eliminated. Treatment ofBOS mainly consists of an increase or a change in theimmunosuppressive drug regimen, which may lead tomore pronounced infectious complications. Recently, twonew options have become available to treat patients withBOS, treatment of gastro-oesophageal reflux andazithromycin. In the present paper, the authors give anoverview of the current data on these two modalities,which may lead to a restoration of the pulmonary

function in some of the patients, illustrating once morethe fact that bronchitis obliterans syndrome is not alwaysa manifestation of chronic rejection.VERLEDEN G.M., DUPONT U., VAN RAEMDONCK D.E.M.:Current issues in lung transplantation. Int. J. Resp. Care,2005; 99-105.Over two decades have passed since long-term survivalwas first achieved following heart-lung and lungtransplantation in humans. Since the beginning of thesuccessful lung transplantation era, survival hasimproved dramatically, but this has been almost entirelydue to reduction in early (90-day) mortality. This is theresult of better surgical techniques and improvements toanaesthetic and perioperative management using veryeffective immunosuppressive drugs and extensiveantibacterial, antifungal and antiviral prophylaxis.Nowadays, a mean actuarial five-year survival of 40-50%can be achieved, even increasing to over 60-70% forselected indications such as cystic fibrosis andemphysema in some high volume centres. Figure 1describes the evolution of survival in the Leuven lungtransplant programma, clearly indicating that earlypostoperative mortality has decreased, but also showingbetter long-term survival, which is mainly due to earlyrecognition and treatment of chronic allograftdysfunction. Although the results seem to improve, thereare still some issues that need resolving before survivalwill match the success of other solid organtransplantations. The aim of this paper is to summarisethese ongoing problems in lung transplantation.VERLEDEN G.M., DUPONT U., VAN RAEMDONCK D.,DELCROIX M., VANHAECKE J., DAENEN W. en de LeuvenseLongtransplantgroep: Long- an hart-longtransplantaties inde Universitaire Ziekenhuizen Leuven: indicaties enresultaten. Tijdschr. voor Geneeskunde, 2005; 61(17): 1230-1235.In dit artikel presenteren we een overzicht van deindicaties en resultaten van 245 hart-long enlongtransplantaties bij 241 patiënten in het UniversitairZiekenhuis Gasthuisberg (U.Z. Leuven).We benadrukken de duidelijke verbetering van deoverlevingsresultaten naarmate de ervaring istoegenomen. Hoewel nog een aantal belangrijkeproblemen blijven bestaan, zijn er de laatste jaren tochmeer mogelijkheden beschikbaar geworden om bv.chronische rejectie vroeger te diagnosticeren en beter tebehandelen. Samen met een belangrijke verminderingvan de perioperatieve mortaliteit, heeft dit ongetwijfeldbijgedragen tot een betere overleving op lange termijn.