What is high risk? Redefining elevated pulmonary vascular resistance index in pediatric heart transplantation

Elevated pre-transplant pulmonary vascular resistance is not associated with mortality in children without congenital heart disease: A multicenter study

“…Perhaps the most unique conclusion of the study is the lack of association between PVRI and early-phase mortality, as most studies are in agreement that there is no association with elevated PVRI and long-term survival (1, 4, 8, 10, 11), but multiple prior publications have reported effects upon early mortality(1, 5,8,12,13). Most of these studies relied upon single-center populations or public registries, both of which have significant limitations, and utilize analysis methods which may be less accurate when examining a time-varying hazard such as death after transplant (7).…”

“…While acute right ventricular failure has been proposed as the mechanism of early death in patients with elevated PVRI (11,(14)(15)(16) this relationship is not clear, especially in the modern era of improved treatment of right ventricular failure (4,9,13,14,16,17). Additionally, decreasing the pulmonary vascular resistance pre-transplant, may or may not have an effect upon early mortality (5,18), suggesting that there are more important factors that play a role in early mortality than pulmonary vascular resistance.…”

“…A PVRI greater than 5 or 6 WU x m 2 has historically been considered a relative contraindication to heart transplantation in pediatric patients due to an increased risk of postoperative right ventricular dysfunction and early mortality (3,4). However, more recent single center studies suggest that current practice may be too restrictive with regards to PVRI, and that excellent outcomes can occur in patients with PVRI above these traditional thresholds (3)(4)(5).…”

Elevated pretransplant pulmonary vascular resistance index does not predict mortality after isolated orthotopic heart transplantation in children: A retrospective analysis of the UNOS database

“…The ongoing concern regarding isolated OHT in patients with elevated PVRI is acute right ventricular dysfunction and subsequent mortality . However, the incidence, ramifications, and management of post‐operative right ventricular dysfunction are all evolving with the broader utilization of targeted therapy for right heart failure including mechanical circulatory support and inhaled nitric oxide.…”

Challenges in Long-Term Mechanical Circulatory Support and Biological Replacement of the Failing Heart

“…It has been argued that higher mortality is observed on the waiting list because of decreased relative use of VAD implantation as a BTT. 32 Peri-transplant mortality is also generally higher in the CHD population, 29 attributed to a number of factors: the need for complex cannulation for cardiopulmonary bypass, 33 adhesions from prior operations, unique extracardiac manifestations of disease such as pulmonary vascular disease, 34 protein-losing enteropathy, coagulopathies and hepatic fibrosis, 35 and frequent need for complex reconstruction at the time of surgery. 3 Despite increased 30-day mortality, long-term outcomes for CHD patients post transplant are excellent and comparable to those for other populations.…”