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Pulmonary Hypertension 

 

 

Considerations 

 

  • Potential for acute perioperative right ventricular (RV) dysfunction & hemodynamic collapse

  • Optimize pulmonary pressures & right heart function:

    • Avoid hypoxia, hypercarbia, acidosis, hypothermia, sympathetic stimulation (pain), high PEEP

    • Cautious fluid administration

    • Maintain RV perfusion

  • Associated conditions (see table below) 

  • Medication management:

    • Anticoagulation

    • Calcium channel blockers 

    • Vasodilators (e.g. sildenafil)

    • Prostacyclin analogs (e.g. epoprostenol/flolan)

    • Endothelin antagonists (e.g. bosantan)

    • Diuretics

  • Need for invasive monitoring, optimized analgesia & post-op disposition

  • Potential or R → L shunt through PFO: hypoxemia & paradoxical emboli 

 

 

Goals 

 

  • Make all attempts to optimize pulmonary vascular resistance (PVR) before surgery

  • Avoid ↑ in PVR (minimize pain, sympathetic stimulation, hypoxia, hypercarbia, acidosis, optimize airway pressures)

  • RV failure management principles: 

    • Optimize RV rate & rhythm: sinus & normal-high rate 

    • Optimize RV filing 

    • Maintain RV perfusion & inotropy 

    • ↓ PVR 

 

 

Conflicts 

 

  • Pulmonary hypertension & laparoscopy:

    • ↑ PaCO2, sympathetic stimulation = bad

    • Case is longer than open

  • Ortho cases with cement, joint replacement (embolic risk)

  • Hemodynamic stability vs need for RSI 

 

 

Pregnancy Considerations

 

  • Hemodynamic goals:

    • Prevent ↑ PVR

    • Maintain intravascular volume & venous return

    • Avoid aortocaval compression

    • Maintain adequate systemic vascular resistance 

    • Avoidance of myocardial depression during general anesthesia 

  • Mode of delivery:

    • Controversial

    • Multidisciplinary meeting required

    • Termination of pregnancy definitely an option as maternal mortality is high

    • Scheduled cesarean section in a controlled setting might be the optimal route

  • Monitoring:

    • High acuity environment preferably in a center with cardiac surgery expertise

    • Standard CAS monitors + 5 lead ECG

    • Arterial line & central line essential

    • PAC a consideration but must weigh risk vs. benefits

  • Anesthetic technique:

    • A carefully titrated epidural likely the best option

    • Avoid ↓ SVR & treat hypotension with fluids/pressors

    • Single shot spinal should be avoided as it can cause severe hemodynamic instability

    • Continuous spinal has been used successfully (slow & careful titration)

    • General anesthesia has been used successfully

    • Potential hazards of GA include ↑ PA pressure during laryngoscopy/intubation, adverse effects of PPV on venous return, & negative inotropic effects of certain anesthetic agents

    • May consider a gentle narcotic-based induction/maintenance, any fetal narcotic effects should be easily reversible 

    • Avoid ergotamine & carboprost; use oxytocin & misoprostol 

 

 

Managing Acute Episodes/Acute RV Failure = 4 Principles 

 

  1. RV Rate & Rhythm: keep sinus & high-normal rate 

  2. RV perfusion & inotropy: maintain with vasopressor/inotrope combo (e.g. norepinephrine & milrinone or epinephrine alone)

  3. RV filling: optimize with CVP, PAC, TEE 

  4. ↓ PA pressures: 

    • Avoid hypercarbia, hypoxemia, acidosis, hypothermia, high airway pressures 

    • Use pulmonary vasodilators: 

      • Nitric oxide: 20-40ppm 

      • Inhaled flolan

      • Milrinone: 0.25-0.75 mcg/kg/min; possible loading dose is 50mcg/kg over 10 min 

 

 

WHO Pulmonary Hypertension Classification 

 

 

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