Severity of pulmonary hypertension
Comorbid features associated with increased riska
Estimated surgical risk
Suggested management strategy
Severe disease
One or more
High
Elective surgery: avoid surgery if possible
• WHO class III/IV
Emergency surgery: obtain cardiac anesthesiology and PH specialist consultation. Consider palliative care or another nonsurgical option. Proceed to surgery with caution if other alternatives are not possible
• mPAP > 55
• PASP > 60
• 6-minute walk: <150 m
Moderate disease
One or more
Medium
Elective surgery: if patient’s pulmonary hypertension has not been optimized through medical management or other means, or if etiology is unclear, then defer surgery. However, if etiology is known, the disease is stable, and no further improvement in severity is expected to occur, then proceed to surgery cautiously
• WHO class II
• mPAP 41–55
• PASP 45–59
• 6-minute walk: 150–400 m
Emergency surgery: proceed with surgery cautiously. Consider cardiac anesthesiologist consultation
Mild disease
None
Low
Elective surgery: proceed with surgery cautiously
• WHO class I
Emergency surgery: not applicable (patients undergoing emergency surgery should be considered to be at medium or high risk in most cases)
• mPAP 26–40
• PASP < 45
• 6-minute walk: >400 m
Perioperative Management
Surgical Planning and Intraoperative Considerations
Detailed intraoperative planning is best left to the anesthesiologist and surgeon working in conjunction with the patient’s pulmonary hypertension specialist. However, the following strategies may reduce surgical risk:
Medication Management
If a patient is being treated with prostacyclins or vasodilators, dosing of these agents should be left to the discretion of the treating anesthesiologist and the patient’s pulmonologist or cardiologist. In many cases the patient’s baseline therapy is continued and vasodilators are used in addition as needed.
Patients who are receiving treatment to control the underlying cause of the pulmonary hypertension should continue this treatment through the perioperative period in most cases (e.g., bronchodilators for COPD).
Some patients with pulmonary hypertension are treated with chronic anticoagulation. Unless the patient is receiving therapy for a separate indication, such patients probably do not require perioperative bridging with heparin. Postoperatively, patients should receive standard venous thromboembolic (VTE) prophylaxis until bleeding risk is acceptable, at which point anticoagulation may be resumed.
Monitoring and Preventing Postoperative Complications
Patients with severe pulmonary hypertension and those requiring intraoperative vasopressors should receive initial postoperative care in an ICU setting [1]. Attention to the following principles may reduce postoperative risk:
Optimize Volume Status
