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Pre-transplant PVR Assessment — EECC MCQ

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HardHeart FailurePre-transplant PVR AssessmentEECC

A 55-year-old man with DCM (LVEF 20%) has recurrent HF hospitalisations despite optimal GDMT. He undergoes right heart catheterisation which shows: RA 12 mmHg, PA 55/25 (mean 35) mmHg, PCWP 25 mmHg, cardiac index 1.8 L/min/m². He is being assessed for cardiac transplantation. The PVR is calculated at 4.0 Wood units. What is the concern regarding transplant candidacy?

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Correct answer: B — Elevated PVR >3 WU may indicate fixed pulmonary hypertension which could cause RV failure of the donor heart post-transplant; vasoreactivity testing is needed

Pre-transplant assessment must include evaluation of pulmonary vascular resistance. Elevated PVR (>3 WU) or transpulmonary gradient (>15 mmHg) indicates pulmonary hypertension that may be irreversible ('fixed'). A normal donor RV cannot tolerate high pulmonary pressures, leading to acute RV failure post-transplant. Vasoreactivity testing with IV nitroprusside, milrinone, or inhaled nitric oxide is performed: if PVR falls to <2.5 WU (reversible component), transplant can proceed. If PVR remains elevated despite vasodilator testing, LVAD implantation as bridge to candidacy may reduce PVR over time by unloading the LV and reducing PCWP. Persistently elevated PVR is a contraindication to heart transplant.

Reference: ISHLT Heart Transplant Guidelines; ESC (2023): HF Guidelines