Effect of lung transplantation on biventricular function in pulmonary arterial hypertension: A systematic review

Pulmonary arterial hypertension (PAH) leads to progressive right ventricular (RV) failure and secondary left ventricular (LV) dysfunction due to chronic pressure overload and ventricular interdependence. Lung transplantation (LTx) is an established treatment for end-stage PAH, yet patterns of biventricular recovery and the role of veno-arterial perioperative extracorporeal membrane oxygenation (VA-ECMO) remain incompletely defined. A PubMed search identified studies published from 1990 to 2025 using MeSH terms related to lung transplantation, ventricular function, echocardiography, cardiac MRI, and ECMO. Prospective studies, retrospective analyses, and case series evaluating post-transplant cardiac function in PAH were included. A total of 13 studies were included. Across studies, LTx resulted in rapid and substantial RV reverse remodeling, with improvements in RV size, mass, systolic function, tricuspid regurgitation, and pulmonary pressures. This reduction in RV afterload was accompanied by progressive improvement of RV output. In contrast, LV recovery was more variable, possibly due to chronic underfilling and LV remodeling. Cardiac MRI and echocardiography demonstrated progressive biventricular structural and functional adaptation over time. Perioperative VA-ECMO may provide hemodynamic support during this transition by unloading the RV and maintaining perfusion while ventricular loading conditions rapidly change. Lung transplantation for PAH initiates transition from chronic RV pressure overload and LV underfilling to improved pulmonary vascular conditions and subsequent biventricular recovery. Further longitudinal studies are needed to identify predictors of maladaptive LV responses and determine which patients may benefit from prolonged perioperative VA-ECMO support.