ISHLT consensus statement: Perioperative management of patients with pulmonary hypertension and right heart failure undergoing surgery

McGlothlin, Dana; Granton, John; Klepetko, Walter; Beghetti, Maurice; Rosenzweig, Erika B.; Corris, Paul A.; Horn, Evelyn M.; Kanwar, Manreet; McRae, Karen; Román, Antonio; Tedford, Ryan J.; Badagliacca, Roberto; Bartolome, Sonja; Benza, Raymond L.; Caccamo, Marco; Cogswell, Rebecca; Dewachter, Céline; Donahoe, Laura; Fadel, Élie; Farber, Harrison W.; Feinstein, Jeffrey A.; Franco, Verónica; Frantz, Robert P.; Gatzoulis, Michael; Goh, Choon Hwa; Guazzi, Marco; Hansmann, Georg; Hastings, Stuart; Heerdt, Paul M.; Hemnes, Anna R.; Herpain, Antoine; Hsu, Chih‐Hsin; Kerr, Kim M.; Kolaitis, N.A.; Kukreja, Jasleen; Madani, Michael M.; McCluskey, Stuart A.; McCulloch, Michael A.; Moser, Bernhard; Navaratnam, Manchula; Rådegran, Göran; Reimer, Cara; Savale, Laurent; Shlobin, Oksana A.; Svetlichnaya, Jana; Swetz, Keith M.; Tashjian, Jessica A.; Thenappan, Thenappan; Vizza, Carmine Dario; West, Shawn C.; Zuckerman, Warren A.; Zuckermann, Andreas; Marco, Teresa De

doi:10.1016/j.healun.2022.06.013

Cited by 27 publications

(43 citation statements)

References 464 publications

(464 reference statements)

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“…On the other hand, patients with group 3 PH are most likely at risk of developing pulmonary complications such as respiratory failure and pneumonia during or after a surgical procedure, which can lead to further RV decompensation. Available data suggest that the overall perioperative risk in non–group 1 PH is increased but less than in patients with group 1 PH, 6 although an accurate identification of risk factors that differentiate these groups is lacking. Armed with the knowledge that RHF is a common perioperative complication in patients with PH, clinicians should focus on supporting the RV function during the surgical procedure and in the following 48 to 72 hours, when the risk for decompensation is the highest.…”

Section: Knowledge Gaps and Research Prioritiesmentioning

confidence: 99%

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Evaluation and Management of Pulmonary Hypertension in Noncardiac Surgery: A Scientific Statement From the American Heart Association

Rajagopal¹,

Ruetzler²,

Ghadimi³

et al. 2023

Circulation

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Pulmonary hypertension, defined as an elevation in blood pressure in the pulmonary arteries, is associated with an increased risk of death. The prevalence of pulmonary hypertension is increasing, with an aging population, a rising prevalence of heart and lung disease, and improved pulmonary hypertension survival with targeted therapies. Patients with pulmonary hypertension frequently require noncardiac surgery, although pulmonary hypertension is associated with excess perioperative morbidity and death. This scientific statement provides guidance on the evaluation and management of pulmonary hypertension in patients undergoing noncardiac surgery. We advocate for a multistep process focused on (1) classification of pulmonary hypertension group to define the underlying pathology; (2) preoperative risk assessment that will guide surgical decision-making; (3) pulmonary hypertension optimization before surgery to reduce perioperative risk; (4) intraoperative management of pulmonary hypertension to avoid right ventricular dysfunction and to maintain cardiac output; and (5) postoperative management of pulmonary hypertension to ensure recovery from surgery. Last, this scientific statement highlights the paucity of evidence to support perioperative pulmonary hypertension management and identifies areas of uncertainty and opportunities for future investigation.

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Section: Knowledge Gaps and Research Prioritiesmentioning

confidence: 99%

“…4 Despite the rising prevalence of PH among patients undergoing noncardiac surgery, there is scant guidance on perioperative management. 5,6 This scientific statement provides a framework and clinical guidance for the evaluation and management of PH in patients undergoing noncardiac surgery.…”

mentioning

confidence: 99%

Evaluation and Management of Pulmonary Hypertension in Noncardiac Surgery: A Scientific Statement From the American Heart Association

Rajagopal¹,

Ruetzler²,

Ghadimi³

et al. 2023

Circulation

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“…47,49 Trendelenburg (head-down) or lithotomy positioning leads to increased venous return with consequent increases in filling pressures and PA and PA wedge pressures, while reverse Trendelenburg (head-up) positioning is associated with venous pooling and hypotension. 2 Orthopaedic Surgery Orthopaedic surgery may result in embolization of cement, marrow, and bone debris which can increase PVR and lead to acute RV deterioration. [50][51][52] Where appropriate, uncemented prostheses should be used to reduce the risk of cement embolization.…”

Section: Procedure-specific Risksmentioning

confidence: 99%

“…47 49 Trendelenburg (head-down) or lithotomy positioning leads to increased venous return with consequent increases in filling pressures and PA and PA wedge pressures, while reverse Trendelenburg (head-up) positioning is associated with venous pooling and hypotension. 2…”

Section: Pulmonary Hypertension and Surgerymentioning

confidence: 99%

“…85 Large tidal volumes and excessive PEEP can compress intra-alveolar capillaries resulting in increased PVR. 2 Ventilation should therefore use a strategy of low tidal volumes of ∼6–8 mL/kg, minimizing peak pressures and maintaining a small amount of PEEP to minimize atelectasis. 86 While anesthetized, any breathing circuit disconnections and loss of PEEP should be minimized to minimize atelectasis.…”

Section: Pulmonary Hypertension and Surgerymentioning

confidence: 99%

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Surgery and Anesthesia in Patients with Pulmonary Hypertension

Condliffe,

Newton,

Bauchmuller

et al. 2023

Semin Respir Crit Care Med

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Pulmonary hypertension is characterized by right ventricular impairment and a reduced ability to compensate for hemodynamic insults. Consequently, surgery can be challenging but is increasingly considered in view of available specific therapies and improved longer term survival. Optimal management requires a multidisciplinary patient-centered approach involving surgeons, anesthetists, pulmonary hypertension clinicians, and intensivists. The optimal pathway involves risk:benefit assessment for the proposed operation, optimization of pulmonary hypertension and any comorbidities, the appropriate anesthetic approach for the specific procedure and patient, and careful monitoring and management in the postoperative period. Where patients are carefully selected and meticulously managed, good outcomes can be achieved.

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Surgical and Device Interventions in the Treatment of Chronic Thromboembolic Disease

et al. 2023

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Chronic thromboembolic pulmonary disease (CTEPD) is characterized by unresolved clot burden in large pulmonary arteries, obstructive disease in smaller arteries, and increased downstream clot burden. This occurs in the setting of abnormal fibrinolysis or hematological disorders. Up to 50% of patients in some studies are unaware of a self-history of a deep venous thrombosis or pulmonary embolism. Ultimately, they present with symptoms of pulmonary hypertension (PH), which can result in right heart failure (RHF). Pulmonary endarterectomy (PEA) is curative, though many patients have prohibitive surgical risk or surgically inaccessible disease, warranting other interventions such as balloon pulmonary angioplasty (BPA) and medical therapy. Rarely, other treatment options may be implemented. We focus this review on PEA and BPA, with an overview of the history of CTEPD and the evolution of these procedures. We will briefly discuss other treatment modalities.

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ISHLT consensus statement: Perioperative management of patients with pulmonary hypertension and right heart failure undergoing surgery

Cited by 27 publications

References 464 publications

Evaluation and Management of Pulmonary Hypertension in Noncardiac Surgery: A Scientific Statement From the American Heart Association

Evaluation and Management of Pulmonary Hypertension in Noncardiac Surgery: A Scientific Statement From the American Heart Association

Surgery and Anesthesia in Patients with Pulmonary Hypertension

Surgical and Device Interventions in the Treatment of Chronic Thromboembolic Disease

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