Perioperative Management Of Pulmonary Hypertension Research Articles

Anesthesia and Pulmonary Hypertension: A Narrative Review

Pulmonary hypertension (PH) is a complex disease of the cardiopulmonary system. Perioperative management of PH is one of the most challenging issues for the anesthetists. Morbidity and mortality are significantly high in PH patients undergoing surgery due to right heart failure, arrhythmia, atrial fibrillation, ischemia, hemodynamic unstability, hypoxia, respiratory failure, renal failure, sepsis, and stroke. In PH patients, it is important that more than one physician, including anesthesiologist, intensivist, pulmonologist, cardiologist, and surgeon, discuss the patient’s possible difficulties and complications with a multidisciplinary approach and make a decision. In order to optimize the management of PH patients, it is necessary to comprehensively evaluate the underlying cause, pathophysiology, risk factors, course, and treatment of the disease. A balanced anesthesia technique, including inhalation or intravenous agents, appropriate regional anesthesia (RA), opioids, and α-2-adrenoceptor agonists, may provide the most uniform hemodynamic profile in these patients. The basis of anesthesia management should be to prevent and treat triggering factors, provide perfusion pressures, and optimize right ventricular functions. Advanced monitoring, pulmonary vasodilator therapies, adequate anesthesia and analgesia, and appropriate ventilator settings should be performed for patients with PH. Patients with PH should be followed in the intensive care unit in the first 48–72 h postoperatively. Our review aims to focus on appropriate preoperative preparation, perioperative monitoring, anesthesia and ventilator management, pain control, preventive methods, and treatment in patients with PH in light of the literature.

Anesthetic Management of an Unusual Case of Severe Pulmonary Hypertensive

The perioperative management of pulmonary hypertension continues to be a great challenge for anesthesiologists. Among the various types of pulmonary hypertension, pulmonary hypertension associated with left heart disease is the most common, while pulmonary hypertensive crisis is one of the causes of perioperative mortality in these patients. We present the case of a 54-year-old female with severe valvular heart disease complicated by severe pulmonary hypertension and massive hemothorax, who underwent emergency exploratory thoracotomy, mitral valve replacement, and tricuspid valvuloplasty. The patient was in critical condition and suspected to have a pulmonary hypertension crisis. The rationale for this case report is to learn about the anesthetic management of patients with severe pulmonary hypertension.

Perioperative Management of Pulmonary Hypertension. a Review.

Pulmonary hypertension is a rare and progressive pathology defined by abnormally high pulmonary artery pressure mediated by a diverse range of aetiologies. It affects up to twenty-six individuals per one million patients currently living in the United Kingdom (UK), with a median life expectancy of 2.8 years in idiopathic pulmonary hypertension. The diagnosis of pulmonary hypertension is often delayed due to the presentation of non-specific symptoms, leading to a delay in referral to specialists services. The complexity of treatment necessitates a multidisciplinary approach, underpinned by a diverse disease aetiology from managing the underlying disease process to novel specialist treatments. This has led to the formation of dedicated specialist treatment centres within centralised UK cities. The article aimed to provide a concise overview of pulmonary hypertension’s clinical perioperative management, including key definitions, epidemiology, pathophysiology, and risk stratification.

Pheochromocytoma Resection in a Patient With Chronic Thromboembolic Pulmonary Hypertension and Thrombocytopenia

PHEOCHROMOCYTOMAS are rare catecholamine-secreting neuroendocrine tumors that can produce life-threatening cardiovascular instability. 1 Lenders JW Eisenhofer G Mannelli M et al. Phaeochromocytoma. Lancet. 2005; 366: 665-675 Abstract Full Text Full Text PDF PubMed Scopus (1279) Google Scholar ,2 Naranjo J Dodd S Martin Y. Perioperative management of pheochromocytoma. J Cardiothorac Vasc Anesth. 2017; 31: 1427-1439 Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar Preoperative management with alpha-blockade and intravascular volume expansion are crucial to intraoperative hemodynamic management, given the risk of catecholamine surges with induction of anesthesia, intubation, surgical incision, insufflation, and tumor manipulation. Intraoperative pheochromocytoma resection management focuses on the goals of maintaining hemodynamic stability in the face of catecholamine surge. After resection, patients are at risk of systemic hypotension related to catecholamine withdrawal, especially in highly active pheochromocytomas. 3 Aguirre MA Lynch I Hardman B. Perioperative management of pulmonary hypertension and right ventricular failure during noncardiac surgery. Adv Anesth. 2018; 36: 201-230 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar

Perioperative Management of Pulmonary Hypertension in Pediatric Cardiac Surgery

Perioperative Management of Pulmonary Hypertension in Pediatric Cardiac Surgery

Perioperative Management of Pulmonary Hypertension in Pediatric Cardiac Surgery

Perioperative Management of Pulmonary Hypertension in Pediatric Cardiac Surgery

Dobutamine and Nitroglycerin Versus Milrinone for Perioperative Management of Pulmonary Hypertension in Mitral Valve Surgery. A Randomized Controlled Study

To compare the effects of dobutamine and nitroglycerin to milrinone in young patients with severe pulmonary hypertension undergoing mitral valve replacement. A prospective randomized, double-blinded, controlled study. Single university hospital. Forty patients had systolic pulmonary arterial pressure ≥60 mmHg and were scheduled for elective mitral valve replacement. The patients were divided randomly into 2 equal groups according to the drugs given during the study. The patients in group I received 5 to 20 µg/kg/min of dobutamine and 0.5 to 3 µg/kg/min of nitroglycerin, and patients in group II received a loading dose of milrinone, 50 µg/kg over 10 minutes, followed by a maintenance dose of 0.25 to 0.75 µg/kg/min. The primary outcome was the effects of interventional drugs on mean pulmonary artery pressure. The secondary outcomes were the effects of interventional drugs on systemic and pulmonary hemodynamic parameters measured from induction of anesthesia until the first 12 hours in the intensive care unit stay. There was a more significant decrease in mean pulmonary artery pressure, pulmonary capillary wedge pressure, and central venous pressure in group II than group I at all time points after cardiopulmonary bypass. There were more significant increases in heart rate, mean arterial pressure, cardiac output, and mixed venous oxygen tension in group I than group II, which became more obvious in time. In both groups, there was a significant decrease in systemic vascular resistance and pulmonary vascular resistance at all times. Milrinone provides adequate cardiac performance, causing a greater reduction in pulmonary artery pressure and pulmonary capillary wedge pressure.

Pulmonary hypertension and cardiac anesthesia: Anesthesiologist's perspective.

Perioperative management of pulmonary hypertension remains one of the most challenging scenarios during cardiac surgery. It is associated with high morbidity and mortality due to right ventricular failure, arrhythmias, myocardial ischemia, and intractable hypoxia. Therefore, this review article is intended toward the anesthetic considerations in the perioperative period, with particular emphasis on the selection of technique and choice of anesthesia with maintenance, anesthetic drugs, and the recent intraoperative recommendations for prevention and treatment of pulmonary hypertensive crisis.

Anesthetic management for palliative arterial switch operation

Objective To summarize the anesthetic management experience for palliative arterial switch operation (PASO). Methods Twenty-eight patients who suffered from transposition of the great arteries(TGA) with septal ventricular defect (TGA/VSD) or Taussing-Bing syndrome underwent PASO were reviewed. The median age was 4 y (ranging from 1 month to 25 y) and the median body weight was 12.5 kg(ranging from 3.6 kg to 43 kg). ALL of them were diagnosed with severe pulmonary hypertension preoperatively. Their preoperative SpO2 was fluctuated from 44% to 91%. Results All anesthetic procedures went smoothly. The mean CPB time was (223± 81) min and the mean cross-clamp time was (153±32) min. The mean size of fenestration in VSD patch was (5.3±1.5) mm. The median postoperative mechanical ventilation time and stay length in intensive care unit was 36 h (ranging from 7 h to 408 h) and 5.5 d (ranging from 2 d to 27 d), respectively. The mean postoperative SpO2 increased significantly to 96% (P<0.05). The mortality rate was 18%. The fenestrations in 5 patients were closed interventionally during 1-5 y after hospital discharge. Conclusions The success of PASO depends on adequate preoperative assessment and preparation, stabel anesthesia induction, management of perioperative pulmonary hypertension and the early and rational administration of cardiovascular drugs, and the adjustment of hemostatic function. Key words: Transposition of the great arteries; Palliative arterial switch operation; Anesthetic management

Pharmacological Management of Perioperative Pulmonary Hypertension: An Update

Aim of review: Pulmonary hypertension (PH) is a complex medical condition with various etiologies and different mechanisms for the pathogenesis. The diagnosis and management of PH has gone through a dramatic transformation process in the last two decades. Better understanding of the molecular pathogenesis of the condition has led to newer therapies which will potentially improve patient survival and overall well-being.Method: This review discussed the current management modalities available for patients with PH.Recent findings: The pharmacological management can be categorized into six major categories: 1). Targeting endothelin pathway (endothelin antagonists); 2). Targeting nitric oxide pathway (inhaled nitric oxide, phosphodiesterase [PDE] inhibitor); 3). Targeting prostaglandin pathway (prostacyclin agonists, thromboxane antagonists); 4). Targeting renin-angiotensin-aldosterone (RAA) pathway; 5). Targeting calcium channels; and 6). General support and other therapies. Commonly we use a combination of available drugs and means and individualize the regimen to each individual patient. Now patients with PH can enjoy a much longer lifespan and better quality of life.Summary: For anesthesiologists, a thorough preoperative evaluation and accurate understanding of patient's status, a delicate intraoperative management and a multidisciplinary integrated postoperative treatment will safeguard our patients to undergo a smooth surgical procedure. Citation: Henry Liu, Philip L. Kalarickal, Geoffrey L. Liu, Hong Yan, Charles J. Fox. Pharmacological management of perioperative pulmonary hypertension: an update. J Anesth Perioper Med 2015; 2: 316-24. doi: 10.24015/JAPM.2015.0042This is an open-access article, published by Evidence Based Communications (EBC). This work is licensed under the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium or format for any lawful purpose. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

Inhaled therapy for the management of perioperative pulmonary hypertension.

Patients with pulmonary hypertension (PH) are at high risk for complications in the perioperative setting and often receive vasodilators to control elevated pulmonary artery pressure (PAP). Administration of vasodilators via inhalation is an effective strategy for reducing PAP while avoiding systemic side effects, chiefly hypotension. The prototypical inhaled pulmonary-specific vasodilator, nitric oxide (NO), has a proven track record but is expensive and cumbersome to implement. Alternatives to NO, including prostanoids (such as epoprostenol, iloprost, and treprostinil), NO-donating drugs (sodium nitroprusside, nitroglycerin, and nitrite), and phosphodiesterase inhibitors (milrinone, sildenafil) may be given via inhalation for the purpose of treating elevated PAP. This review will focus on the perioperative therapy of PH using inhaled vasodilators.

Perioperative management of pulmonary hypertension during lung transplantation (a lesson for other anaesthesia settings)

Patients with pulmonary hypertension are some of the most challenging for an anaesthesiologist to manage. Pulmonary hypertension in patients undergoing surgical procedures is associated with high morbidity and mortality due to right ventricular failure, arrhythmias and ischaemia leading to haemodynamic instability. Lung transplantation is the only therapeutic option for end-stage lung disease. Patients undergoing lung transplantation present a variety of challenges for anaesthesia team, but pulmonary hypertension remains the most important. The purpose of this article is to review the anaesthetic management of pulmonary hypertension during lung transplantation, with particular emphasis on the choice of anaesthesia, pulmonary vasodilator therapy, inotropic and vasopressor therapy, and the most recent intraoperative monitoring recommendations to optimize patient care.

Pharmacologic Management of Perioperative Pulmonary Hypertension

Perioperative pulmonary hypertension can originate from an established disease or acutely develop within the surgical setting. Patients with increased pulmonary vascular resistance are consequently at greater risk for complications. Despite the various specific therapies available, the ideal therapeutic approach in this patient population is not currently clear. This article describes the basic principles of perioperative pulmonary hypertension and reviews the different classes of agents used to promote pulmonary vasodilation in the surgical setting.

Scheduled perioperative switch from oral sildenafil to intravenous epoprostenol in a patient with Eisenmenger syndrome undergoing a sigmoidectomy

The perioperative management of pulmonary hypertension in a patient with Eisenmenger syndrome, the most advanced form of associated pulmonary artery hypertension (PAH), who required a sigmoidectomy is presented. The treatment for pulmonary hypertension was switched from oral sildenafil to intravenous epoprostenol to avoid the unexpected discontinuation of vasodilation during the perioperative period. The scheduled perioperative conversion should be considered for patients with severe PAH undergoing major abdominal surgery to ensure the stabilization of pulmonary and systemic hemodynamics.

Perioperative Management of Pulmonary Hypertension in Children with Critical Heart Disease

Pulmonary hypertension (PHTN) is common to a variety of conditions occurring in infants and children presenting to the intensive care unit. A fundamental understanding of the response of the right ventricle to an increase in afterload and the clinical syndromes responsible for PHTN is essential for managing patients with PHTN and critical heart disease. There are important distinguishing features between PHTN syndromes, and although one form of PHTN may predominate, often more than one mechanism of PHTN is contributing to the pathophysiologic state. Thus, it is imperative to tailor therapies accordingly in order to optimize outcomes.

Perioperative management of pulmonary hypertension

Perioperative management of pulmonary hypertension

Pro: Inhaled Prostaglandin as a Pulmonary Vasodilator Instead of Nitric Oxide

PERIOPERATIVE MANAGEMENT of pulmonary hypertension (PHTN) is important because it significantly affects perioperative outcome. Perioperative PHTN and accompanying right ventricular (RV) failure are major predictors for mortality after coronary artery bypass grafting, left ventricular assist-device placement, and heart transplantation. 1 Maslow A. Regan M. Panzica P. et al. Precardiopulmonary bypass right ventricular function is associated with poor outcome after coronary artery bypass grafting in patients with severe left ventricular systolic dysfunction. Anesth Analg. 2002; 95: 1507-1518 Crossref PubMed Scopus (159) Google Scholar , 2 Fukamachi K. McCarthy P.M. Smedira N. et al. Preoperative risk factors for right ventricular failure after implantable left ventricular assist device insertion. Ann Thor Surg. 1999; 68: 2181-2184 Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar , 3 Augoustides J.G. Ochroch E.A. Perioperative use of nitric oxide in cardiothoracic anesthesia and intensive care. Prog Anesth. 2001; 15: 115-124 Google Scholar Inhaled nitric oxide (iNO) was the first selective pulmonary vasodilator that allowed selective pulmonary vasodilation with no systemic vasodilation. This pharmacologic breakthrough represented a significant advance in the perioperative management of PHTN and RV dysfunction. 3 Augoustides J.G. Ochroch E.A. Perioperative use of nitric oxide in cardiothoracic anesthesia and intensive care. Prog Anesth. 2001; 15: 115-124 Google Scholar , 4 Augoustides J.G. Mancini D.J. Postoperative care of the adult cardiac surgical patient. Prog Anesth. 2002; 16: 99-112 Google Scholar , 5 Steudel W. Hurford W. Zapol W. Inhaled nitric oxide Basic biology and clinical applications. Anesthesiology. 1999; 91: 1090-1121 Crossref PubMed Scopus (133) Google Scholar , 6 Blaise G. Langleben D. Hubert B. Pulmonary arterial hypertension Pathophysiology and anesthetic approach. Anesthesiology. 2003; 99: 1415-1432 Crossref PubMed Scopus (153) Google Scholar , 7 Fischer L.G. Van Atken H. Burkle H. Management of pulmonary hypertension and pharmacological considerations for anesthesiologists. Anesth Analg. 2003; 96: 1603-1616 Crossref PubMed Scopus (156) Google Scholar

Treatment of Rebound Pulmonary Hypertension: Why Not Sildenafil?

Alder Hey Hospital, Liverpool, United Kingdom. drrajashahzad@hotmail.comI read with great interest the case report by Augoustides et al. 1published in the April issue of Anesthesiology. They highlight the important issue of rebound pulmonary hypertension after withdrawal of inhaled prostacyclin and make a case for the use of inhaled iloprost. They propose that inhaled iloprost may allow gradual controlled withdrawal of perioperative inhaled selective pulmonary vasodilation, probably as a result of its favorable pharmacokinetics. Hence, in their opinion it has great promise in the management of perioperative pulmonary hypertension after cardiac surgery. However, I think that if the authors had highlighted the advantages of using sildenafil, instead of iloprost, in this scenario their case report would have made a more lasting and useful contribution to the existing literature on the topic of management of rebound pulmonary hypertension.Pulmonary hypertension remains a major complication after surgical correction of congenital and long-standing valvular heart disease. Inhaled nitric oxide has been shown to reduce, but not eliminate, potentially life-threatening episodic pulmonary hypertensive crises.2Nitric oxide increases intracellular cyclic guanosine monophosphate, resulting in smooth muscle vasodilation. Phosphodiesterase type 5 is responsible for cyclic guanosine monophosphate breakdown in lung tissue. Abrupt discontinuation of nitric oxide may be complicated by life-threatening events, and phosphodiesterase activity may play a role in this phenomenon.3Sildenafil (Viagra; Pfizer Laboratories, New York, NY), a selective and potent inhibitor of phosphodiesterase type 5, augments pulmonary vasodilation with nitric oxide and reduces the risk of pulmonary hypertensive crises in an at-risk postoperative patient.4Furthermore, it ameliorates the rebound pulmonary hypertension caused by withdrawal of inhaled pulmonary vasodilators.5Compared with the standard treatment, inhaled nitric oxide, sildenafil is superior in decreasing the mean pulmonary artery pressure and equally effective and selective in reducing pulmonary vascular resistance.6It also causes a significant increase in the cardiac index.6Its availability in oral, inhaled and intravenous forms, longer half-life of 4 h,4and proven efficacy in randomized controlled trials7–9are some of the distinguishing features which make sildenafil first-choice agent for managing rebound pulmonary hypertension.Thus, my question for Augoustides et al. is “Why inhaled iloprost and not sildenafil?”Alder Hey Hospital, Liverpool, United Kingdom. drrajashahzad@hotmail.com

Chapter 15 Perioperative Management of Pulmonary Hypertension and Right Heart Failure

Chapter 15 Perioperative Management of Pulmonary Hypertension and Right Heart Failure

Management of peri-operative pulmonary hypertension in a patient presenting for a portosystemic shunt

We report the successful management of intraoperative pulmonary hypertension in a patient with mitral valve insufficiency and portal hypertension. A 48-year-old male with portal hypertension presented for a portosystemic shunt. Previously undiagnosed mitral valve insufficiency and pulmonary hypertension complicated his anaesthetic management. His intraoperative course was marked by systolic hypotension, pulmonary hypertension and a reduction in cardiac output. The use of nitric oxide in this patient reduced right ventricular afterload, increased cardiac output, without exacerbating pre-existing systolic hypotension.