What are the risks of surgery for a patient with pulmonary arterial hypertension (PAH)?

From the Guidelines

Surgery for patients with pulmonary arterial hypertension (PAH) carries significant risks and should be avoided unless absolutely necessary, with careful preoperative optimization and postoperative monitoring in a specialized center. The main risks include acute right heart failure, hemodynamic collapse, refractory hypoxemia, and potentially fatal pulmonary hypertensive crises during or after surgery. These patients have limited cardiac reserve and are extremely sensitive to changes in preload, afterload, and cardiac contractility that occur during anesthesia and surgical procedures. Specific complications include arrhythmias, thromboembolism, bleeding (especially if on anticoagulants), and respiratory failure requiring prolonged mechanical ventilation. The perioperative mortality rate is substantially higher than in the general population, ranging from 4-24% depending on PAH severity and the type of surgery 1.

To minimize these risks, patients should continue their PAH-specific medications (such as prostacyclins, endothelin receptor antagonists, and phosphodiesterase inhibitors) throughout the perioperative period. Careful preoperative optimization with a multidisciplinary team including PAH specialists, anesthesiologists, and surgeons is essential. When possible, regional anesthesia is preferred over general anesthesia, and invasive hemodynamic monitoring is typically required to guide management during surgery. The most recent guidelines suggest avoiding non-essential surgery and using a multidisciplinary approach for necessary surgeries, with careful monitoring and management of clinical status, oxygenation, and hemodynamics postoperatively 1.

Some key considerations for the management of PAH patients undergoing surgery include:

• Avoiding non-essential surgery
• Care at a pulmonary hypertension center
• Multidisciplinary approach including the pulmonary hypertension team, surgical service, and cardiovascular anesthesiology
• Careful monitoring and management of clinical status, oxygenation, and hemodynamics postoperatively
• Continuing PAH-specific medications throughout the perioperative period
• Preoperative optimization and postoperative monitoring in a specialized center.

Overall, the management of PAH patients undergoing surgery requires careful consideration of the potential risks and benefits, and a multidisciplinary approach to minimize complications and optimize outcomes.

From the Research

Risks of Surgery for Patients with Pulmonary Arterial Hypertension (PAH)

The risks of surgery for patients with PAH are significant and include:

• Increased risk of perioperative morbidity and mortality 2, 3, 4, 5
• Excess perioperative risk due to the underlying pathology of PAH 2
• Risk of acute right ventricular failure and cardiac output dysfunction 3, 4, 5
• Risk of systemic hypotension and arrhythmias precipitating right ventricular ischemia 4

Preoperative Risk Assessment and Management

Preoperative risk assessment and management are crucial to reduce the risks associated with surgery in patients with PAH. This includes:

• Classification of PAH group to define the underlying pathology 2
• Preoperative risk assessment to guide surgical decision-making 2, 5
• Optimization of PAH before surgery to reduce perioperative risk 2, 4, 5
• Individualized preoperative risk assessment and optimization 5

Intraoperative and Postoperative Management

Intraoperative and postoperative management are critical to preventing complications in patients with PAH. This includes:

• Close monitoring of the patient's condition 4, 5
• Prevention of systemic hypotension and acute elevations in pulmonary arterial pressure 4
• Use of vasopressors and pulmonary vasodilators as necessary 4
• Advanced perioperative planning and a tailored-individualized perioperative plan 5

Surgical Treatment Options

Surgical treatment options are available for patients with PAH, including:

• Pulmonary endarterectomy to cure PAH in cases of obstruction of the pulmonary arteries 6
• Transplantation in end-stage PAH after failure of medical treatment 6
• Atrial septostomy and Potts procedure as palliative surgical procedures to delay transplantation 6
• Extracorporeal cardiopulmonary support as a bridge to transplantation or during recovery after transplantation or pulmonary endarterectomy 6