Pulmonary hypertension (PH) is a haemodynamic manifestation of cardiorespiratory and
non-cardiorespiratory pathologies. Cardiorespiratory pathologies account for nearly
three-fourths of patients with PH. It is now increasingly being recognised due to
routine requests for transthoracic echocardiographic examination in the perioperative
setting in patients undergoing intermediate- to high-risk non-cardiac surgery. The
increased risks of perioperative morbidity and mortality attributed to PH have been
widely acknowledged in the literature. The importance of PH in perioperative decision-making
and postoperative outcomes has had little mention in all the guidelines. Understanding
the complexity of the pathophysiology of PH may help in anaesthetic and surgical decision-making.
Preoperative evaluation and risk assessment are guided by the nature, extent, invasiveness,
and duration of surgery. Surgical decision-making and anaesthetic management involve
preoperative risk stratification, understanding the interactions between surgical
procedures and PH, and understanding the interactions between anaesthetic procedures,
PH, and cardiopulmonary interactions. Intraoperative and postoperative monitoring
is crucial for maintaining the haemodynamic parameters and helps titrate anaesthetic
agents and medication. This narrative review focusses on all issues related to anaesthetic
and surgical challenges in patients with PH. This review aimed to suggest a preoperative
evaluation plan, surgical decision-making, anaesthetic plan, and anaesthetic management
based on the evidence available in the literature.
Keywords
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References
- Haemodynamic definitions and updated clinical classification of pulmonary hypertension.Eur Respir J. 2019; 53: 1801913
- Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review.Eur Respir J. 2009; 34: 888-894
- Mechanisms of disease: pulmonary arterial hypertension.Nat Rev Cardiol. 2011; 8: 443-455
- Biphasic effect of transforming growth factor-beta 1 on in vitro angiogenesis.Exp Cell Res. 1993; 204: 356-363
- TGF-beta induces bimodal proliferation of connective tissue cells via complex control of an autocrine PDGF loop.Cell. 1990; 63: 515-524
- Immunolocalization of BMPR-II and TGF-B type I and II receptors in primary plexogenic pulmonary hypertension.J Heart Lung Transplant. 2001; 20: 149
- Activin receptor-like kinase 1 modulates transforming growth factor-beta 1 signaling in the regulation of angiogenesis.Proc Natl Acad Sci U S A. 2000; 97: 2626-2631
- Role of serotonin in the pathogenesis of acute and chronic pulmonary hypertension.Thorax. 1999; 54: 161-168
- Coagulation and fibrinolytic profiles in patients with severe pulmonary hypertension.Chest. 1996; 110: 710-717
- Endothelin-1 and serotonin: mediators of primary and secondary pulmonary hypertension?.J Lab Clin Med. 1999; 134: 105-114
- Endothelial nitric oxide synthase in the lungs of patients with pulmonary hypertension.N Engl J Med. 1995; 333: 1642-1644
- Endothelin-1 is elevated in monocrotaline pulmonary hypertension.Am J Physiol. 1999; 276: L304-L310
- Elevated levels of plasma endothelin-1 in young patients with pulmonary hypertension caused by congenital heart disease are decreased after successful surgical repair.J Thorac Cardiovasc Surg. 1995; 110: 271-273
- Plasma endothelin concentrations in patients with pulmonary hypertension associated with congenital heart defects: Evidence for increased production of endothelin in pulmonary circulation.Circulation. 1991; 84: 2280-2285
- Direct role for potassium channel inhibition in hypoxic pulmonary vasoconstriction.Am J Physiol. 1992; 262: C882-C890
- Molecular identification of the role of voltage-gated K+ channels, Kv1. 5 and Kv2.1, in hypoxic pulmonary vasoconstriction and control of resting membrane potential in rat pulmonary artery myocytes.J Clin Invest. 1998; 101: 2319-2330
- Cardiopulmonary dysfunction in cirrhosis.J Gastroenterol Hepatol. 1999; 14: 600-608
- Effects of the arteriovenous fistula on pulmonary artery pressure and cardiac output in patients with chronic renal failure.J Vasc Access. 2009; 10: 160-166
- Prevalence, Diagnosis, Perioperative Monitoring and Treatment of Right Ventricular Dysfunction and/or Pulmonary Arterial Hypertension in Cardiac Surgical Patients in Germany-A Postal Survey.Thorac Cardiovasc Surg. 2017; 65: 593-600
- Pulmonary hypertension: prevalence and mortality in the Armadale echocardiography cohort.Heart. 2012; 98: 1805-1811
- Pulmonary arterial hypertension: baseline characteristics from the REVEAL Registry.Chest. 2010; 137: 376-387
- Pulmonary arterial hypertension in France: results from a national registry.Am J Respir Crit Care Med. 2006; 173: 1023-1030
- An epidemiological study of pulmonary arterial hypertension.Eur Respir J. 2007; 30: 104-109
- Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients.Eur J Cardiothorac Surg. 1999; 15: 816-822
- Intraoperative hemodynamic predictors of mortality, stroke, and myocardial infarction after coronary artery bypass surgery.Anesth Analg. 1999; 89: 814-822
- Preoperative pulmonary hemodynamics and early mortality after orthotopic cardiac transplantation: the Pittsburgh experience.Am Heart J. 1993; 126: 896-904
- The Registry of the International Society for Heart and Lung Transplantation: seventeenth official report-2000.J Heart Lung Transplant. 2000; 19: 909-931
- Gomberg-Maitland M, et al. Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey.Eur Respir J. 2013; 41: 1302-1307
- Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality.J Am Coll Cardiol. 2005; 45: 1691-1699
- Surgical intervention in patients with moderate to severe pulmonary arterial hypertension.Conn Med. 2006; 70: 239-243
- Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension.Eur Respir J. 2010; 35: 1294-1302
- Time from symptoms to definitive diagnosis of idiopathic pulmonary arterial hypertension: the delay study.Pulm Circ. 2013; 3: 89-94
- The changing landscape of pulmonary arterial hypertension and implications for patient care.Eur Respir Rev. 2014; 23: 450-457
- Guiliani E.R. Pulmonary hypertension, Mayo Clinic Practice of Cardiology. 3rd edition. Mosby, St. Louis1996: 1815-1836
- Primary pulmonary hypertension: a national prospective study.Ann Intern Med. 1987; 107: 216-223
- ESC Scientific Document Group. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: the Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT).Eur Heart J. 2016; 37: 67-119
- Inhaled nitric oxide as a screening vasodilator agent in primary pulmonary hypertension: a dose-response study and comparison with prostacyclin.Am J Respir Crit Care Med. 1995; 151: 384-389
- Inhaled nitric oxide as a cause of selective pulmonary vasodilatation in pulmonary hypertension.Lancet. 1991; 338: 1173-1174
- International Liver Transplant Society Practice Guidelines: diagnosis and management of hepatopulmonary syndrome and portopulmonary hypertension.Transplantation. 2016; 100: 1440-1452
- Does portopulmonary hypertension impede liver transplantation in cirrhotic patients? A French multicentric retrospective study.Transplantation. 2018; 102: 616-622
- Diagnosis of portopulmonary hypertension in candidates for liver transplantation: a prospective study.Hepatology. 2003; 37: 401-409
- Liver transplantation and cardiac illness: current evidences and future directions.J Hepatobiliary Pancreat Sci. 2020; 27: 225-241
- Reversibility of pulmonary hypertension after liver transplantation: a case report.Transplant Proc. 1993; 25: 1789-1790
- Resolution of pulmonary hypertension of cirrhosis after liver transplantation.Transplantation. 1994; 58: 1133-1135
- Pulmonary hypertension is associated with reduced patient survival after kidney transplantation.Transplantation. 2008; 86: 1384-1388
- Pulmonary hypertension is an independent predictor of mortality in hemodialysis patients.Kidney Int. 2009; 75: 969-975
- Pulmonary hemodynamics and perioperative cardiopulmonary-related mortality in patients with portopulmonary hypertension undergoing liver transplantation.Liver Transplant. 2000; 6: 443-450
- Importance of relative pulmonary hypertension in cardiac surgery: the mean systemic-to-pulmonary artery pressure ratio.J Cardiothorac Vasc Anesth. 2006; 20: 331-339
- Recent trends in early outcome of adult patients after heart transplantation: a single-institution review of 251 transplants using standard donor organs.Am J Transplant. 2002; 2: 539-545
- Selection of cardiac transplantation candidates in 2010.Circulation. 2010; 122: 173-183
- Pulmonary hypertension: an important predictor of outcomes in patients undergoing non-cardiac surgery.Respir Med. 2011; 105: 619-624
- Perioperative mortality in patients with pulmonary hypertension undergoing major joint replacement.Anesth Analg. 2010; 111: 1110-1116
- Combined lung and liver transplantation: the United States experience.Transplantation. 2005; 80: 1161-1167
- Combined transplantation of the heart, lung and liver.Lancet. 2001; 358: 812-813
- Combined liver and (heart-)lung transplantation in liver transplant candidates with refractory portopulmonary hypertension.Transplantation. 2002; 73: 140-144
- Heart-lung-liver transplantation.J Heart Lung Transplant. 1996; 15: 536-538
- Transplantation of liver, heart, and lungs for primary biliary cirrhosis and primary pulmonary hypertension.Lancet. 1987; 2: 182-185
- Kidney transplantation in valvular heart disease and pulmonary hypertension: consensus in waiting.Clin Transplant. 2021; 35 (Erratum in: Clin Transplant. 2021:e14342)e14116
- International Society for Heart and Lung Transplantation The registry of the International Society for Heart and Lung Transplantation: thirty-third adult lung and heart-lung transplant report-2016; focus theme: primary diagnostic indications for transplant.J Heart Lung Transplant. 2016; 35: 1170-1184
- ENABLE investigators and committees. Long-term effect of endothelin receptor antagonism with bosentan on the morbidity and mortality of patients with severe chronic heart failure: primary results of the ENABLE trials.JACC Heart Fail. 2017; 5: 317-326
- Hemodynamic and gas exchange effects of sildenafil in patients with chronic obstructive pulmonary disease and pulmonary hypertension.Am J Respir Crit Care Med. 2010; 181: 270-278
- Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement.Br J Anaesth. 2021; 126: 774-790
- How to improve long-term outcome after liver transplantation?.Liver Int. 2018; 38: 134e8
- The effect of high doses of calcium-channel blockers on survival in primary pulmonary hypertension.N Engl J Med. 1992; 327: 76-81
- et al. Long-term response to calcium channel blockers in idiopathic pulmonary arterial hypertension.Circulation. 2005; 111: 3105-3111
- Long-term response to calcium-channel blockers in non-idiopathic pulmonary arterial hypertension.Eur Heart J. 2010; 31: 1898-1907
- Sildenafil citrate therapy for pulmonary arterial hypertension.N Engl J Med. 2005; 353: 2148-2157
- Addition of sildenafil to long-term intravenous epoprostenol therapy in patients with pulmonary arterial hypertension: a randomized trial.Ann Intern Med. 2008; 149: 521-530
- Bosentan therapy in patients with Eisenmenger syndrome: a multicenter, double-blind, randomized, placebo-controlled study.Circulation. 2006; 114: 48-54
- Ambrisentan for the treatment of pulmonary arterial hypertension: results of the ambrisentan in pulmonary arterial hypertension, randomized, double-blind, placebo-controlled, multicenter, efficacy (ARIES) study 1 and 2.Circulation. 2008; 117: 3010-3019
- Macitentan and morbidity and mortality in pulmonary arterial hypertension.N Engl J Med. 2013; 369: 809-818
- Macitentan for the treatment of inoperable chronic thromboembolic pulmonary hypertension (MERIT-1): results from the multicentre, phase 2, randomised, double-blind, placebo-controlled study.Lancet Respir Med. 2017; 5: 785-794
- Primary Pulmonary Hypertension Study Group A comparison of continuous intravenous epoprostenol (prostacyclin) with conventional therapy for primary pulmonary hypertension.N Engl J Med. 1996; 334: 296-301
- Continuous subcutaneous infusion of treprostinil, a prostacyclin analogue, in patients with pulmonary arterial hypertension: a double-blind, randomized, placebo-controlled trial.Am J Respir Crit Care Med. 2002; 165: 800-804
- Upfront triple combination therapy in pulmonary arterial hypertension: a pilot study.Eur Respir J. 2014; 43: 1691-1697
- Selexipag for the treatment of pulmonary arterial hypertension.N Engl J Med. 2015; 373: 2522-2533
- Atrial septostomy improves survival in select patients with pulmonary hypertension.Am Heart J. 2007; 153: 779-784
- Interventional and surgical therapeutic strategies for pulmonary arterial hypertension: beyond palliative treatments.J Cardiol. 2015; 66: 304-314
- Atrial septostomy in treatment of end-stage right heart failure in patients with pulmonary hypertension.Chest. 2007; 131: 977-983
- Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension?.Eur Heart J. 2009; 30: 256-265
- Pulmonary hypertension and pregnancy outcomes: systematic review and meta-analysis.Eur J Obstet Gynecol Reprod Biol. 2020; 253: 108-116
- NO-body's perfect.Anesthesiology. 2002; 96: 1285-1287
- Inhaled prostacyclin (PGI2) is an effective addition to the treatment of pulmonary hypertension and hypoxia in the operating room and intensive care unit.C J Anesth. 2001; 48: 924-929
- The use of iloprost in early pregnancy in patients with pulmonary arterial hypertension.Eur Resp J. 2005; 26: 168-173
- Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review.Crit Care. 2010; 14: R169
- The effect of phenylephrine and norepinephrine in patients with chronic pulmonary hypertension∗.Anaesthesia. 2002; 57: 9-14
- Effects of vasopressin on right ventricular function in an experimental model of acute pulmonary hypertension.Crit Care Med. 2002; 30: 2548-2552
- Outcome after cardiopulmonary resuscitation in patients with pulmonary arterial hypertension.Am J Respir Crit Care Med. 2002; 165: 341e4
- ECMO and right ventricular failure: review of the literature.J Intensive Care Med. 2021; 36: 352-360
- Veno-arterial ECMO in severe acute right ventricular failure with pulmonary obstructive hemodynamic pattern.J Invasive Cardiol. 2010; 22: 365-369
- Mechanical circulatory support devices for acute right ventricular failure.Circulation. 2017; 136: 314-326
- Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology.Eur J Heart Fail. 2016; 18: 226-241
- Impact of intra-aortic balloon pumping on hypotension and outcomes in acute right ventricular infarction.Coron Artery Dis. 2014; 25: 602-607
- Left ventricular systolic dysfunction is associated with adverse outcomes in acute right ventricular infarction.Coron Artery Dis. 2016; 27: 277-286
Article info
Publication history
Published online: February 23, 2023
Accepted:
January 3,
2023
Received in revised form:
November 3,
2022
Received:
September 21,
2021
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2023 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
