Heart transplantation (HTx) has been associated to significant improvements in survival and quality of life in patients with advanced heart failure (HF). Despite a considerable increase in the indication of left ventricular assistant devices, HTx still remains the gold-standard approach in this clinical context. Even though it is considered the gold-standard treatment for advanced HF, several reasons have impaired the widespread utilization of the HTx. There is limited availability of donors compared with the growing potential recipients. Moreover, the longer life expectancy of the patients due to better HF pharmacotherapy has been challenging the age-related contraindication for the procedure, as well as the presence of more comorbidities linked to aging.

Another point to be observed related to HTx candidacy is pulmonary hypertension (PH), which is present in more than 60% of HF patients with reduced ejection fraction (HFrEF) and over 54% of patients with HF and preserved ejection fraction (HFpEF) and also might account for up to 50% of post-HTx complications. An elevated pulmonary vascular resistance (PVR) > 2.5 Wood units is linked to a nearly 30% increase in mortality within the first-month post-transplant. This HF-associated PH is considered to be the result of the passive effect of increased left ventricular end-diastolic pressure along with vasoreactivity secondary to vasoconstriction and arterial pulmonary remodeling.^, When not reversible with a vasodilator challenge, it has been strongly associated with right ventricular dysfunction, HF hospitalizations, worsening in quality of life, and reduced survival. The International Society for Heart and Lung Transplantation guidelines consider the presence of severe pre-transplant PH as a relative contraindication to heart transplantation.

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