What is pulmonary hypertension (PH)?

Updated: Sep 11, 2019
  • Author: Swapnil Khoche, MBBS, DNB, FCARCSI; Chief Editor: Sheela Pai Cole, MD  more...
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Answer

Answer

It is estimated that pulmonary hypertension (PH) affects about 1% of the global population and as many as 10% of persons older than 65 years. [1, 2]  Until relatively recently, patients with this condition were considered to be at prohibitively high risk for undergoing elective procedures. This situation has changed: Greater knowledge of the pathophysiology of PH and advances in its treatment have led to improvements in both functional status and life expectancy for these patients.

PH has been associated with an increase in perioperative morbidity and mortality, particularly when complicated by an acute pulmonary hypertensive crisis and a failing right ventricle (RV). [3, 4, 5]  As data regarding the risks (and also safety) of noncardiac surgery in patients with PH continue to accumulate, it is imperative for anesthesiologists to educate themselves about PH. This article focuses on salient aspects of the perioperative management of patients with PH who present for noncardiac surgical procedures.

Key points in the management of a patient with PH include the following:

  • PH is a disease that is associated with significant perioperative morbidity and mortality
  • Acute pulmonary hypertensive crisis can lead to acute RV failure and carries a high mortality
  • Patients with PH should undergo a thorough preoperative evaluation, including right-heart catheterization and echocardiography, to assess disease severity
  • PH can be exacerbated by metabolic derangements such as hypoxia, hypercarbia, and acidosis, as well as by pain 
  • In the setting of severe PH, pulmonary artery (PA) catheter insertion, transesophageal echocardiography (TEE), or both are indicated for guiding appropriate pharmacologic therapy
  • Vasoactive medications that increase inotropy, vasodilate the pulmonary circulation, and spare the systemic circulation are ideal
  • Dobutamine and phenylephrine are preferred because they have a quick onset of action, are easily titrated, and improve the RV perfusion-to-demand ratio
  • Dopamine and epinephrine are useful in situations involving fixed lesions, such as chronic thromboembolic PH (CTEPH)
  • Inhaled nitric oxide (iNO) is a useful adjunct if available, providing preferential vasodilation of the pulmonary circulation in ventilated portions

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