Management of Pulmonary Hypertension in Noncardiac Surgery: Key Points

Rajagopal S, Ruetzler K, Ghadimi K, et al., on behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, and the Council on Cardiovascular and Stroke Nursing.
Evaluation and Management of Pulmonary Hypertension in Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2023;Mar 16:[Epub ahead of print].

The following are key points to remember from an American Heart Association (AHA) Scientific Statement on the evaluation and management of pulmonary hypertension (PH) in noncardiac surgery:

  1. In the United States, the presence of PH during major noncardiac surgeries has increased over time and is independently associated with major adverse cardiovascular and cerebrovascular events. Despite this rising prevalence of PH among patients undergoing noncardiac surgery, there is scant guidance on perioperative management.
  2. PH is a heterogenous group of disorders that results in elevation of pulmonary artery (PA) pressures. The PH clinical classification distinguishes five groups:
    • Pulmonary arterial hypertension (PAH) (Group 1 PH or PAH).
    • PH associated with left-sided heart disease (Group 2 PH).
    • PH associated with lung disease or hypoxia (Group 3 PH).
    • PH associated with chronic pulmonary artery obstruction (Group 4 PH).
    • PH with unclear or multifactorial mechanisms (Group 5 PH).
  3. Some predictors of perioperative complications in patients with PH include emergent procedures, elevated right atrial pressure (≥7 mm Hg), decreased 6-minute walking distance, history of pulmonary embolism, right-axis deviation on electrocardiography, right ventricular (RV) systolic pressure to systemic pressure ration >0.66, and elevated N-terminal pro–B-type natriuretic peptide levels (≥300 pg/mL).
  4. It is recommended to perform a preoperative risk assessment based on the specific PH clinical group:
    • PAH: Evaluation by a PH specialist with risk assessment utilizing clinical risk scores: REVEAL 2.0 score or European Society of Cardiology/European Respiratory Society (ESC/ERS) risk scoring.
    • Group 2 PH: Utilization of cardiac preoperative scores to estimate perioperative risk: 2014 AHA/American College of Cardiology (AHA/ACC) guidelines, Revised Cardiac Risk Index (RCRI), Vascular Quality Initiative (VQI) Cardiac Risk Index.
    • Group 3 PH: Utilization of pulmonary preoperative scores to estimate perioperative risk: ARISCAT Risk Index, Arozullah respiratory failure index, Gupta calculator for postoperative respiratory failure.
    • Group 4 PH: Evaluation by a PH specialist with risk assessment utilizing clinical risk scores: REVEAL 2.0 score or ESC/ERS risk scoring and perioperative anticoagulation plan.
    • Group 5 PH: Evaluation by specialist based on the primary condition associated with PH (e.g., hematology if lymphoproliferative disorders or hemolytic anemia) followed by evaluation for a PH specialist.
    • The preoperative PH risk should be balanced with the surgical risk/benefit.
  5. Optimization of PH prior to surgery should include medical assessment and consideration for adjustment of PAH-specific therapies, diuretics, respiratory therapies, participation in pulmonary rehabilitation, and arrhythmia management.
  6. The intraoperative hemodynamic goals include:
    • Avoid systemic hypotension.
    • Maintain normal sinus rhythm.
    • Avoid factors known to increase pulmonary vascular resistance (PVR), such as hypoxia, hypercarbia, acidosis, hypothermia, and pain.
    • Avoid high airway pressure and positive end-expiratory pressure.
    • Maintain RV loading conditions.
    • The choice of type of anesthesia is specific to the procedure and patient.
    • Medication considerations: Etomidate has minimal effect in PVR, heart rate, and contractility. Ketamine is associated with an increase in PVR and therefore should be avoided. Propofol can affect RV contractility and should be used with caution. A rapid sequence indication using succinylcholine or rocuronium, fentanyl, and lidocaine is commonly used. Any inhalational agent can be used for maintenance except for nitrous oxide due to its effect in increasing PVR.
  7. Intraoperative PH management:
    • Monitoring is recommended with an invasive arterial catheter. The decision for central venous catheter (with or without pulmonary artery catheter) should be based on the severity of RV dysfunction and PH and the level of surgical risk.
    • Patients who are on parenteral PAH-specific therapy should continue it without interruption. Sildenafil is available for intravenous administration if needed. Nitric oxide and inhaled epoprostenol efficacy and safety are comparable.
    • There are no comparative studies of vasopressors and inotropes in PH, and recommendations are based on expert opinions. Norepinephrine and vasopressin are generally preferred over phenylephrine. Both milrinone and dobutamine have inotropic, systemic, and pulmonary vasodilator effects and may lead to severe systemic vascular hypotension, requiring the addition of a vasopressor.
  8. The postoperative management of PH should be targeted to avoid conditions that can cause elevation in PVR.
    • Monitoring of oxygen, end-tidal CO2, and blood pressure is paramount for early detection of clinical derangements.
    • Optimizing pain control before leaving the operating room is a key principle.
    • Inotropes are the hallmark of medical management of cardiogenic shock from RV failure. To promote RV-PA coupling, inhaled pulmonary vasodilators can be used to lower PVR.
    • VV-extracorporeal membrane oxygenation (ECMO) can be used to improve oxygenation, although it requires a relatively normal RV function. VA-ECMO for refractory RV failure refractory to medical therapy would be the usual mechanical support modality and it can be used as a bridge to decision-making.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Heart Failure and Cardiac Biomarkers, Pulmonary Hypertension, Hypertension

Keywords: Acidosis, Anemia, Anticoagulants, Arrhythmias, Cardiac, Atrial Pressure, Central Venous Catheters, Diuretics, Dobutamine, Electrocardiography, Extracorporeal Membrane Oxygenation, Familial Primary Pulmonary Hypertension, General Surgery, Hematology, Hypertension, Pulmonary, Hypotension, Hypothermia, Natriuretic Peptide, Brain, Perioperative Care, Postoperative Care, Pulmonary Embolism, Pulmonary Surgical Procedures, Risk Assessment, Risk Factors, Secondary Prevention, Vascular Resistance, Vasodilator Agents, Vasopressins

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