Pulmonary vein stenosis after pediatric heart transplantation: incidence and risk factors

Postoperative pulmonary vein stenosis (PVS) is an uncommon but potentially serious complication following pediatric heart transplantation. This study aimed to determine the prevalence of PVS and identify donor- and recipient-related predictors.

We retrospectively reviewed pediatric patients (<18 years) who underwent heart transplantation at a single center between 2003 and 2024. PVS was defined as a ≥ 4 mmHg Doppler gradient across any pulmonary vein on echocardiography or significant narrowing on computed tomography. Donor and recipient variables-including congenital heart disease (CHD), predicted heart mass (PHM), donor-recipient size/sex were analyzed using univariate and multivariable logistic regression. The primary endpoint was the occurrence of PVS; the secondary endpoint was overall mortality.

Among 50 recipients (median age, 11 years; range, 0.2-17 years), 9 (18%) developed de novo PVS with a median time to diagnosis of 84 days (range, 4-1088 days). On univariate analysis, CHD (p = 0.007), PHM (p = 0.017), and male-to-female donor-recipient mismatch (p = 0.035) were significantly associated with PVS. In multivariate analysis, CHD remained the only associated factor (p = 0.015; OR, 11.25; 95% CI, 1.60-78.98). PVS did not significantly affect survival probability (p = 0.240).

PVS occurred in nearly one-fifth of pediatric heart transplant recipients, predominantly in those with CHD. However, given the limited sample size, these findings should be considered exploratory and hypothesis-generating. Donor-recipient size mismatch parameters were consistently greater among patients with PVS, though this association warrants validation in larger prospective cohorts. Although PVS was not associated with increased mortality, identification of high-risk groups remains essential for surveillance and preventive strategies in pediatric heart transplantation.