Preoperative balloon pulmonary angioplasty enabled noncardiac surgery of a patient with chronic thromboembolic pulmonary hypertension (CTEPH)

Abstract

Rationale:Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease with a poor prognosis, characterized by chronic thromboembolic obstruction of the pulmonary arteries and pulmonary hypertension. Balloon pulmonary angioplasty (BPA) is a newly emergent treatment for CTEPH, which may substitute pulmonary endarterectomy, the standard but more invasive treatment for CTEPH. Here, we report the case of a CTEPH patient who underwent 2 noncardiac surgeries without complications after preoperative intervention of BPA.Patient concerns:A 79-year-old man presented with severe osteoarthritis of bilateral knees, with adaptation of total knee arthroplasty (TKA). Transthoracic echocardiogram revealed severe pulmonary hypertension with estimated right ventricular systolic pressure of 140 mm Hg.Diagnosis:Pulmonary arteriography revealed total occlusion of the upper branch of the right pulmonary artery, and ventilation/perfusion scan showed multiple mismatched perfusion defects. His pulmonary artery pressure (PAP) was as high as 89/25 (46) mm Hg with normal range of pulmonary capillary wedge pressure. He was diagnosed with CTEPH.Interventions:Four BPA sessions for 8 branches of the bilateral pulmonary arteries were done, until the mean PAP (mPAP) went under 30 mm Hg. For the TKA, we selected spinal anesthesia in order to minimize intraoperative hemodynamic changes. Cardiac surgeons were standby in case extracorporeal membrane oxygenation (ECMO) initiation was required.Outcomes:With appropriate pain management and use of intravenous vasopressors, intraoperative vital signs were stable. No symptoms of hemodynamic collapse were observed postoperatively. The patient was discharged on the 46th postoperative day following rehabilitation. Two years later, left-side unicompartment knee arthroplasty (UKA) was scheduled. Right heart catheterization study revealed the mPAP was 30 mm Hg, nearly the same value as the last study. The operation was performed under spinal anesthesia with continuous arterial pressure monitoring without need for intraoperative vasopressor. He was discharged without complications on the 24th postoperative day.Lessons:BPA can be an effective preoperative intervention for CTEPH patients undergoing noncardiac surgery.

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

“…Examples include the initiation or augmentation of PAH specific therapies for patients with WHO Group I PAH; administration of oxygen, bronchodilators, antibiotics, and steroids for patients with chronic obstructive pulmonary disease (COPD); use of BIPAP for patients with obstructive sleep apnea (OSA); and systemic vasodilators and other appropriate HF therapies for patients with WHO Group 2 PH. Additionally, pulmonary balloon angioplasty has been successfully performed pre-operatively for CTEPH prior to non-cardiac surgery to reduce peri-operative risk (19).…”

Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement

“…Although the presence of PH is recognised in US guidelines to be a risk factor for postoperative complications, 56 no scoring systems exist that specifically predict perioperative risk in patients with PH. Individualised risk assessment is therefore important.…”

Perioperative approach to precapillary pulmonary hypertension in non-cardiac non-obstetric surgery

“…treprostinil in pregnancy with severe PH; those patients subsequently underwent caesarean section. BPA procedures have been described with promising results in preoperative management of selected patients with CTEPH undergoing noncardiac surgery and can be proposed in non-urgent surgery [67,68]. Multiple sessions of BPA were employed in CTEPH patients to reduce mPAP below 30 mmHg prior to total hysterectomy and knee arthroplasty, which resulted in a successful outcome [67,68].…”