What is included in the preoperative evaluation of a patient 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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Answer

Answer

Preoperative evaluation

A thorough preoperative evaluation should be performed to assess the severity of the disease process, with particular attention paid to functional status, comorbid conditions, and the proposed procedure. The approach to perioperative care of patients with PH is often a multidisciplinary one that includes input from PH experts, surgeons, intensivists, pharmacists, and nursing staff. A careful assessment of the need for surgery, with a focus on the risk-to-benefit ratio in each individual patient, is the difficult task that falls on this group of caregivers.

A detailed history and a thorough physical examination should be complemented by a review of vital investigations—namely ECG, chest radiography, pulmonary function tests, brain natriuretic peptide (BNP) or other markers of heart failure, functional assessment or stress testing, echocardiography, and right-heart catheterization. [12]  Dyspnea and fatigue are nonspecific symptoms, but angina and syncope are ominous indicators of advanced disease. [18]  Multimodal assessment of volume status can be vital in optimizing RV preload.

Echocardiography (either TEE or transthoracic echocardiography [TTE]) can provide an estimate of pulmonary artery pressures and right-heart function. It provides insight into the functional reserve of the RV, its degree of compensation, and the anticipated need for inotropic or pulmonary vasodilator support. RV functional parameters, such as TAPSE and RV fractional area change, can be extremely useful for this purpose. [9]  

Typically, a right-heart catheterization is performed in patients with severe PH who are undergoing elective surgery; this is the gold standard for characterizing disease severity. An mPAP of 25-40 mm Hg signifies mild disease, an mPAP of 40-55 mm Hg signifies moderate disease, and an mPAP higher than 55 mm Hg signifies severe disease.

Evaluation of intracardiac pressures is also essential for characterizing the effects of pressure overload on the right heart and determining whether a patient is nearing the limits of compensation. Typically, normal RAP is lower than 5 mm Hg, RV systolic pressure is lower than 25 mm Hg, and RV diastolic pressure is lower than 5 mm Hg. A combination of high RAP with reduced cardiac output is more concerning than a pure elevation in PAP would be because it points toward right-side pump failure.

Vasoreactivity in response to a calcium-channel blocker may identify patients who will benefit from intraoperative pulmonary vasodilation, which is commonly achieved by administering iNO. [9]  A left-heart catheterization may be performed if there are concerns about possible severe CAD, left-side valvular disease, or inaccuracy in the measurement of PAWP.


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