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.