How is preoperative risk assessed in patients with pulmonary hypertension (PH)?

Updated: Sep 11, 2019
  • Author: Swapnil Khoche, MBBS, DNB, FCARCSI; Chief Editor: Sheela Pai Cole, MD  more...
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The most notable risks for patients with PH are as follows [12] :

  • Perioperative mortality
  • RV failure
  • Prolonged intubation
  • Major arrhythmia

Key factors to consider in assessing a patient with PH include the following:

  • Nature of the surgical procedure
  • Functional status
  • Severity of PH
  • Associated comorbid conditions

Patients with PH who undergo minor procedures (eg, endoscopy or breast surgery) have lower complication rates than similar patients who undergo high- or intermediate-risk procedures (eg, laparoscopic abdominal, thoracic, vascular, or emergency procedures). Increased disease severity, as suggested by elevations in systolic and mean PAP, has also been associated with a higher complication rate. [13, 14] ​ Furthermore, the presence of comorbid conditions such as coronary artery disease (CAD) or chronic kidney disease has been associated with increased risk and by itself changes the American Society of Anesthesiologists (ASA) physical status score. 

In the presence of heart failure, hypoxia, or acidosis that is amenable to optimization, it is perhaps best to give additional consideration to the decision to proceed with elective surgery. [9]  Even when medical status is optimized, it is easy to imagine that patients with PH represent a high-risk subgroup when undergoing noncardiac surgery. [15] Predictors of adverse outcome include the following:

  • History of pulmonary embolism
  • New York Heart Association (NYHA) functional class II or above
  • Emergency or high-risk surgery
  • RV hypertrophy
  • RV systolic pressure higher than two thirds of systemic pressure
  • Intraoperative inotrope use

The presence of one or more of these red flag characteristics may warrant more invasive monitoring (eg, pulmonary artery catheterization or TEE) intraoperatively. Echocardiographic parameters that predict a poor outcome include the following:

  • Severe right atrial (RA) enlargement
  • Reduced tricuspid annular plane systolic excursion (TAPSE)
  • Degree of interventricular septal flattening
  • Pericardial effusion

To summarize, dyspnea at rest, low cardiac output in the face of severely elevated right-side filling pressures, metabolic acidosis, and marked hypoxia point toward severe and potentially life-threatening disease that should prompt reassessment of the need for surgery before further optimization.

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