Pulmonary Hypertension: Cardiac and Non-Cardiac Surgery

 Yes, In every patient with a known history of pulmonary hypertension, that is admitted for evaluation prior cardiac surgery, an echo is done in order to reevaluate its condition and the efficacy of medical treatment.

A combination of inotrpic agents that act through different molecular pathways is possible and worthy of consideration in case of patients in need of inotropic support. The main goal of haemodynamic managment is to avoid exacerbation of preexisting pulmonary hypertension, support systemic blood pressure and myocardial contractillity.

The use of pulmonary vasodilators is generally contraindicated in case of severe left ventricular dysfunction, because their use decreases pulmonary artery pressure, increasing left ventricular preload.

The use of Pulmonary Artery Catheter(Swan-Ganz) allows the continous measurment of pulonary artery pressures itraoperatively and in the postoperative period. TOE permits the estimation of pulmonary artery pressure in presence of some degree of tricuspid regurgitation allowing at the same time the evaluation of right and left ventricular function. In case of severe pulmonary hypertension, combined use of  Pulmonary Artery Catheter and TOE can be very helpful in the perioperative period.

All standart IV agents and volatile anaeshtetics can be used for the induction of anaesthesia.Histamine releasing factors (i.e. Atracurium) should be avoided. A balanced approach of anaesthesia characterized by haemodynamic stability is the best choise.

"A very interesting article regarding this issue is:Levosimendan in pulmonary hypertension and right heart failure.Pulmonary Circulation 2018; 8(3) 1–7

DOI: 10.1177/2045894018790905"

There is no evidence that IV induction or induction using volatile anaesthetics is related to better outcomes. All agents appropriately titrated can be used in order to ensure haemodynamic stability.

We do not use enoxamine. This drug is not available in Greece.

In our department we have never used volatile agents in the ICU.Despite this, there are  studies published that highlight the use of volatile agents in the cardiac ICU ,but are not specific for PH patients.It is known that Sevoflurane causes bronchodilation ,improving oxygenation .In addition, studies have shown that Sevo in the ICU, after cardiac surgery has cardioprotective effect, as it reduces the serum troponin levels , in comparison to iv agents.It also improves delirium.So it would be a challenge to use volatile agents in Icu in the future and  examine their effect.

We usually take the PAC out 24-48 hours after extubation and when we are sure that the patient is stable and responds well to treatment.There are no guidelines in our ICU on that, and we customize our practice to the patient.We are always careful for infection arrhythmias or other complications but so far we have never faced a major one

This was obviously a misunderstanding. ASA warns against "exsessive" use of oxygen, in total agreement with your first sentence, not against O2. 

Not really, non-cardiac anesthesiologists are not familiar with its use yet. 

This was a cancer procedure and there was a concern that if ASD was first repaired, by the time the patient would be fit for his thoracic surgery the tumor would be inoperable.

This was also an idea that came up, but would also very much delay the thoracic procedure, due to delays related with bureaucratic reasons in country of residence. Again, the concern was that the tumor would be inoperable by then.

For an elective surgery, and if he did not have the  aortic stenosis, would basically apply all recommendations given by the literature so far. Would timely switch to non- enteral pulmonary vasodilators, continuing intraoperatively. Would also proceed with RA/PNB, if applicable. In case GA was required, would monitor with both PAC and TOE. Use of vasopressors as needed and fluid monitoring. Postoperatively, ICU monitoring to wean off the non-enteral agents and return to oral medication. For the second part of your question, I believe you meant for cardiac surgery, as this was a non- cardiac surgery at first place. For cardiac surgery, would have a similar preoperative optimization and his ASD would be also addressed intraoperatively.

I have found only a few studies investigating the liability of PAC during one lung ventilation, most of them conducted on animals. Clinical significance in changes was found to be minor. Additionally, the trends, combined with the rest of the monitoring can offer guidance. All values mentioned during the presentation were obtained during two lung ventilation.

No studies compare GA to RA in PH patients at the moment. However, with the existing evidence, literature agrees on RA when applicable.

No studies have compared laparoscopic to open approach in PH patients yet. However, since laparoscopic surgery is associated with speeder recovery and less postoperative pain, whereas not all procedures require positions to hemodynamically affect the patient, the technique is not considered off the table. Literature, however, advises on immediate conversion to open approach when necessary.

Thank you for this very interesting question. I do not think there is one answer that fits all, but we are talking about a non- elective case, and basically low risk patients regarding their PH, since they are asymptomatic. However, a thorough preoperarive medical history, a physical examination and the standard preoperative checking would reveal the patients to be further screened.

No studies compare GA to RA in PH patients at the moment. However, with the existing evidence, literature agrees on RA when applicable. Nevertheless, anxiety control should be easier addressed than the consenquences of Positive Pressure Ventilation.

The Onassis Cardiac Surgery Center is the premier cardiovascular surgery and interventional cardiology hospital in Greece, certified with ISO 9001:2015. It provides a complete spectrum of services in cardiac surgery and cardiology for all forms of acquired and congenital heart disease, including heart and lung adult transplantations. Its clinical results are comparable to those of the best centers in Europe and the USA 

Among patients with RV dysfunction as a result of pressure overload, precapillary PH and left-sided heart failure are the most common etiologies. Effective strategies to optimize cardiopulmonary hemodynamics and support RV function are paramount. If pharmacological therapies are maximized but fail to stabilize the patient with RV failure, mechanical support should be considered. RVAD insertion is deemed necessary in case the RV can not provide adequate volume to LVAD even after maximizing the pharmacological approach

The de-escalation from MCS  should become on a daily basis by evaluating the cardiac function with TOE and hemodynamics. According to the patient's vitals gradually reduce pump speed by 0.5 L/min decrements to 2 L/min, optimizing simultaneously the inotropic and vasopressor support.  In the case, that hemodynamics and  echo study reveal improvement of these parameters we should start de-escalating the patient from temporary MCS support

We rarely use implella in our patients

Optimal coupling occurs when the maximum stroke work is achieved with the minimum cardiac oxygen consumption. Pharmacological and fluid management aims at utilizing myocardial energy reserves in order to optimize LV preload and RV contractility. Thus the heart can provide adequate output without elevating its metabolic demand. TAPSE/systolic PAP ratio has been considered a valid index for the noninvasive evaluation of RV–arterial coupling.

contractility in order to provide suboptimal stroke work, but for higher efficiency. 

The administration of a combination of inhaled pulmonary vasodilators   acting through different pathways, for example, PDE5 and prostenoid inhalers, help RV function in a such away that the RV could provide adequate CO to LVAD which is desirable.