Pre-transplant PVR Assessment — EECC MCQ

Correct answer: D — Elevated TPG (>15 mmHg) or PVR (>5 WU) indicates fixed pulmonary vascular resistance that may cause fatal donor RV failure post-transplant — a vasoreactivity challenge (with nitric oxide, milrinone, or nitroprusside) determines reversibility; irreversible elevation may require combined heart-lung transplant or LVAD to allow PVR reduction before transplant

Pre-transplant haemodynamic assessment is critical because: the donor heart has a normal RV that is NOT conditioned for high afterload. If recipient PVR is significantly elevated, the donor RV will acutely fail against the high pulmonary resistance, causing death. The ISHLT/ESC HF Guidelines: (1) TPG >15 mmHg or PVR >5 WU (Wood units): transplant carries high risk of donor RV failure; (2) vasoreactivity testing: administer IV vasodilator (inhaled NO, milrinone, nitroprusside) during RHC → if PVR falls to <2.5 WU and TPG <15 mmHg: reversible (transplant can proceed); (3) if PVR is FIXED (irreversible): options include: LVAD implantation (improves forward flow → reduces LA pressure → reduces PA pressure over weeks-months — PVR may become reversible), then re-evaluate for transplant; or combined heart-lung transplant (if PVR remains fixed). Serial haemodynamic assessment during LVAD support monitors PVR trajectory toward transplant eligibility.

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