WAIT LIST MANAGEMENT AND BRIDGING STRATEGIES
Waitlist management is aimed at increasing the patient’s prospect of survival while waiting and improving post-transplant outcomes. In general, it includes nutritional, physical rehabilitation and adjustments of targeted PH pharmacotherapy as indicated. For pulmonary vascular disorders the interventions are aimed at maximizing pulmonary blood flow and improving oxygen delivery and may include diuretics, anticoagulation, supplemental oxygen, and other therapies targeted at the pulmonary vasculature. Atrial septostomy and Pott’s shunt procedures are reserved for patients with refractory pulmonary hypertension13, these therapies will be further discussed in other manuscripts in this Supplement {references from the Editor}.
Extracorporeal life support is an invasive, potentially life-sustaining technology that can be used in patients with persistent right ventricular failure without response to medical treatment. Historically veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was considered a contraindication as a bridge to lung transplantation due to poor outcomes 14. Survival has improved due to advances in ECMO technology, anticoagulation and enhanced experience in leading pediatric centers with high priority ECLS teams. Veno-venous ECMO has been used in selected clinical PH patients whereby oxygenated blood can be directed through a large atrial septal defect into the left atrium. More recently the group at Texas Children’s Hospital bridged two PVOD patients with VA-ECMO using central cannulation approach (Gazzaneo MC, personal communication). Preliminary discussion about bridging strategies should take place during the evaluation and should be determined by the time of listing in the event of clinical deterioration before organs become available. These bridging strategies should be limited to centers with standardized best practice protocols15.