Original Article

Multidisciplinary Perioperative Management of Pulmonary Arterial Hypertension in Patients Undergoing Noncardiac Surgery

Authors: José L. Díaz-Gómez, MD, Juan G. Ripoll, MD, Isabel Mira-Avendano, MD, John E. Moss, MD, Gavin D. Divertie, MD, Ryan D. Frank, MS, Charles D. Burger, MD


Objectives: To describe the effect of implementing a contemporary perioperative pulmonary hypertension (PH)–targeted protocol in patients with pulmonary arterial hypertension (PAH) undergoing noncardiac surgery (NCS).

Methods: The data of consecutive patients with PAH diagnosed by right heart catheterization who underwent NCS between January 1, 2006 and February 9, 2016 were reviewed. Patient demographics, etiology of PAH, clinical features, diagnostic data, utilization of PH-specific medications, and trend of perioperative complications rate were recorded during the study period.

Results: In the base cohort of 375 patients, 37 had NCS. The mean age at surgery was 62 years. Most patients were women (78%) classified in group 1 PAH. At the time of the surgery, 86% were New York Heart Association functional class III/IV and 97% had American Society of Anesthesiologists classifications 3 and 4. A larger proportion of patients displayed lower PAH risk scores between 2006 and 2011 (P = 0.045). Conversely, a higher percentage of patients exhibited moderately high to very high PAH risk scores between 2012 and 2016 (P = 0.003). Perioperative and anesthetic-related morbidity was 27%, and no difference was observed between either period (P = 0.944). Most of the complications (70%) were related to general anesthesia. Two deaths (5%) occurred in our study group, both during the 2006–2011 period.

Conclusions: The combination of a multidisciplinary perioperative approach, utilization of novel pulmonary vascular disease–targeted therapy, adequate perioperative optimization, and thoughtful selection of anesthetic technique seems to be a potential strategy to at least maintain similar perioperative outcomes among higher- and lower-risk patients with PAH undergoing NCS.


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1. Pilkington SA, Taboada D, Martinez G. Pulmonary hypertension and its management in patients undergoing non-cardiac surgery. Anaesthesia 2015;70:56-70.
2. McLaughlin VV, Shah SJ, Souza R, et al. Management of pulmonary arterial hypertension. J Am Coll Cardiol 2015;65:1976-1997.
3. Kuralay E, Demirkilic U, Oz BS, et al. Primary pulmonary hypertension and coronary artery bypass surgery. J Card Surg 2002;17:79-80.
4. Reich DL, Bodian CA, Krol M, et al. Intraoperative hemodynamic predictors of mortality, stroke, and myocardial infarction after coronary artery bypass surgery. Anesth Analg 1999;89:814-822.
5. Rodriguez RM, Pearl RG. Pulmonary hypertension and major surgery. Anesth Analg 1998;87:812-815.
6. Beck JR, Mongero LB, Kroslowitz RM, et al. Inhaled nitric oxide improves hemodynamics in patients with acute pulmonary hypertension after high-risk cardiac surgery. Perfusion 1999;14:37-42.
7. Hartz RS. Surgery for chronic thromboembolic pulmonary hypertension. World J Surg 1999;23:1137-1147.
8. McCurry KR, Keenan RJ. Controlling perioperative morbidity and mortality after lung transplantation for pulmonary hypertension. Semin Thorac Cardiovasc Surg 1998;10:139-143.
9. Snopek G, Pogorzelska H, Zielinski T, et al. Valve replacement for aortic stenosis with severe congestive heart failure and pulmonary hypertension. J Heart Valve Dis 1996;5:268-272.
10. Sundaresan S. The impact of bronchiolitis obliterans on late morbidity and mortality after single and bilateral lung transplantation for pulmonary hypertension. Semin Thorac Cardiovasc Surg 1998;10:152-159.
11. Xie GY, Lin CS, Preston HM, et al. Assessment of left ventricular diastolic function after single lung transplantation in patients with severe pulmonary hypertension. Chest 1998;114:477-481.
12. Pasque MK, Trulock EP, Cooper JD, et al. Single lung transplantation for pulmonary hypertension. Single institution experience in 34 patients. Circulation 1995;92:2252-2258.
13. Lai HC, Lai HC, Wang KY, et al. Severe pulmonary hypertension complicates postoperative outcome of non-cardiac surgery. Br J Anaesth 2007;99:184-190.
14. Ramakrishna G, Sprung J, Ravi BS, et al. Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality. J Am Coll Cardiol 2005;45:1691-1699.
15. Price LC, Montani D, Jais X, et al. Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension. Eur Respir J 2010;35:1294-1302.
16. Kaw R, Pasupuleti V, Deshpande A, et al. Pulmonary hypertension: an important predictor of outcomes in patients undergoing non-cardiac surgery. Respir Med 2011;105:619-624.
17. Minai OA, Venkateshiah SB, Arroliga AC. Surgical intervention in patients with moderate to severe pulmonary arterial hypertension. Conn Med 2006;70:239-243.
18. Enderby CY, Burger C. Medical treatment update on pulmonary arterial hypertension. Ther Adv Chronic Dis 2015;6:264-272.
19. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;130:2215-2245.
20. Simonneau G, Gatzoulis MA, Adatia I, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol 2013;62(25 Suppl):D34-D41.
21. Galie N, Simonneau G. The Fifth World Symposium on Pulmonary Hypertension. J Am Coll Cardiol 2013;62(25 Suppl):D1-D3.
22. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002;166:111-117.
23. Arena R, Lavie CJ, Milani RV, et al. Cardiopulmonary exercise testing in patients with pulmonary arterial hypertension: an evidence-based review. J Heart Lung Transplant 2010;29:159-173.
24. Arena R, Myers J, Williams MA, et al. Assessment of functional capacity in clinical and research settings: a scientific statement from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing. Circulation 2007;116:329-343.
25. Neal JE, Lee AS, Burger CD. Submaximal exercise testing may be superior to the 6-min walk test in assessing pulmonary arterial hypertension disease severity. Clin Respir J 2014;8:404-409.
26. Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality. JAMA 1961;178:261-266.
27. Miller MR, Crapo R, Hankinson J, et al. General considerations for lung function testing. Eur Respir J 2005;26:153-161.
28. Benza RL, Gomberg-Maitland M, Miller DP, et al. The REVEAL Registry risk score calculator in patients newly diagnosed with pulmonary arterial hypertension. Chest 2012;141:354-362.
29. Badesch DB, Abman SH, Ahearn GS, et al. Medical therapy for pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest 2004;1:126(1 Suppl):35S-62S.
30. Badesch DB, Abman SH, Simonneau G, et al. Medical therapy for pulmonary arterial hypertension: updated ACCP evidence-based clinical practice guidelines. Chest 2007;131:1917-1928.
31. McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians American Thoracic Society, Inc. and the Pulmonary Hypertension Association. J Am Coll Cardiol 2009;53:1573-1619.
32. Task Force for Diagnosis and Treatment of Pulmonary Hypertension of European Society of Cardiology (ESC), European Respiratory Society (ERS), International Society of Heart and Lung Transplantation (ISHLT).et al. Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2009;34:1219-1263.
33. Galie N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension: the Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J 2016;37:67-119.
34. Meyer S, McLaughlin VV, Seyfarth HJ, et al. Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey. Eur Respir J 2013;41:1302-1307.
35. Jain S, Khera R, Girotra S, et al. Comparative effectiveness of pharmacologic interventions for pulmonary arterial hypertension: a systematic review and network meta-analysis. Chest 2017;151:90-105.
36. Blaise G, Langleben D, Hubert B. Pulmonary arterial hypertension: pathophysiology and anesthetic approach. Anesthesiology 2003;99:1415-1432.
37. Bennett JM, Ehrenfeld JM, Markham L, et al. Anesthetic management and outcomes for patients with pulmonary hypertension and intracardiac shunts and Eisenmenger syndrome: a review of institutional experience. J Clin Anesth 2014;26:286-293.
38. Jiang ZY, Costachescu T, Derouin M, et al. Treatment of pulmonary hypertension during surgery with nitric oxide and vasodilators. Can J Anaesth 2000;47:552-555.
39. Fishman AP. Respiratory gases in the regulation of the pulmonary circulation. Physiol Rev 1961;41:214-280.
40. Martin JT, Tautz TJ, Antognini JF. Safety of regional anesthesia in Eisenmenger' syndrome. Reg Anesth Pain Med 2002;27:509-513.
41. Bedard E, Dimopoulos K, Gatzoulis MA. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension? Eur Heart J 2009;30:256-265.
42. Tikkanen J, Hovi-Viander M. Death associated with anaesthesia and surgery in Finland in 1986 compared to 1975. Acta Anaesthesiol Scand 1995;39:262-267.