Management of Severe Pulmonary Hypertensive Disease for Surgical and Nonsurgical Procedures

Inflammatory Basis of Pulmonary Arterial Hypertension

“…anesthesiologists and critical care physicians alike. 9 Their perioperative risk has primarily been evaluated through retrospective studies, [10][11][12][13][14] partly limited by differences in methodology and consideration of combined World Health Organization pulmonary hypertension groups. Yet, together they uniformly speak to the considerable risk of morbidity and mortality in patients with pulmonary arterial hypertension across the perioperative period, [10][11][12][13][14][15] above that seen in other types of pulmonary hypertension.…”

“…11 Given the high risk of morbidity and mortality in the perioperative period for patients with pulmonary arterial hypertension, delaying elective procedures to undertake a thorough preoperative evaluation by a multidisciplinary team with specific consultation with a pulmonary hypertension specialist is warranted. 9 Pulmonary arterial hypertension is itself an independent predictor of perioperative complications. 17 Patient-risk factors of morbidity and mortality include a right atrial pressure greater than 7 mmHg and a 6-min walk test shorter than 399 m. 15 The preoperative period is thus an opportunity to optimize medical therapy and exercise capacity.…”

“…The management of severe pulmonary hypertension in the operative setting has similarly been comprehensively reviewed. 9 In this review, we deal separately with the chronic management of pulmonary arterial hypertension (the main focus herein) and the rescue of acute, decompensated right-sided heart failure or an acute PVR crisis. In the acute setting, the importance of pulmonary vasodilators and inotropic support cannot be overemphasized: reduction in PVR and support of the right ventricle represent the anesthesiologist's most pressing priorities.…”

“…The cellular pathways in question involve L-type calcium channels, endothelin-1, nitric oxide, and prostacyclin. 9,20 Calcium channel blockers, specifically indicated for the subset of patients demonstrating positive vasoactive testing in the cardiac catheterization laboratory, can be used at high doses and should be terminated or supplemented by other drugs if no effect is noted. 6 Of note, significant systemic hypotension may arise as a result of calcium channel blockade in this population.…”

“…26 For acute use, inhaled NO can be attached to an anesthesia circuit for rapid addition, and has a long history of successful use in the acute intraoperative setting. 9 The ongoing INOvation-1 trial is a placebo-controlled, randomized, controlled trial designed to evaluate the long-term safety and efficacy of inhaled NO in pulmonary arterial hypertension (clinicaltrials.gov NCT02725372). The chronic vasodilatory effects of sildenafil and other drugs discussed herein should give pause to anesthesiologists, as they can cause hypotension, have antiplatelet effects, and may also inhibit hypoxic pulmonary vasoconstriction during thoracic surgery and one-lung ventilation.…”