What is the preoperative assessment for pulmonary hypertension (PH)?

From the Guidelines

Preoperative assessment for pulmonary hypertension should include a thorough evaluation of the patient's current pulmonary status, right ventricular function, and optimization of therapy before surgery, as recommended by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1.

Key Components of Preoperative Assessment

• A detailed history and physical examination, focusing on symptoms like dyspnea, fatigue, chest pain, and syncope
• Laboratory tests, including complete blood count, comprehensive metabolic panel, BNP or NT-proBNP, and coagulation studies
• Imaging studies, with echocardiography being the cornerstone to assess right ventricular function, estimate pulmonary artery pressure, and evaluate for valvular disease
• Right heart catheterization may be necessary for definitive diagnosis and hemodynamic assessment, with pulmonary hypertension defined as mean pulmonary artery pressure ≥20 mmHg at rest
• Pulmonary function tests, arterial blood gases, and six-minute walk tests help evaluate functional capacity

Preoperative Optimization

• Continuing all pulmonary hypertension medications (such as phosphodiesterase-5 inhibitors, endothelin receptor antagonists, prostacyclins) through the perioperative period
• Optimizing volume status, treating right heart failure if present, and ensuring adequate oxygenation
• The anesthesia team should be alerted early about the patient's condition to plan appropriate monitoring, including consideration of intraoperative pulmonary artery catheterization

Risk Stratification

• Patients with severe pulmonary hypertension (particularly with right ventricular dysfunction) have significantly higher perioperative morbidity and mortality, and elective procedures may need to be postponed until better optimization is achieved
• Risk factors for perioperative adverse events in patients with pulmonary hypertension include the severity of pulmonary hypertension symptoms, the degree of RV dysfunction, and the performance of surgery in a center without expertise in pulmonary hypertension 1

Perioperative Management

• Perioperative administration of short-acting inhaled pulmonary vasodilators (eg, nitric oxide, aerosolized prostacyclins) may be reasonable to reduce elevated RV afterload and prevent acute decompensated right HF 1
• A multi-disciplinary team, including surgeons and cardiac anesthesiologists, should formulate an approach to the perioperative care, focusing on the choice of induction and maintenance anesthetic agents, close intra-operative monitoring, and plan for pulmonary vasodilator therapy during and after surgery 1

From the Research

Preoperative Assessment for Pulmonary Hypertension

Preoperative assessment for patients with pulmonary hypertension is crucial to minimize the risk of perioperative morbidity and mortality. The following points highlight the key considerations:

• Patients with pulmonary hypertension are at increased risk for perioperative complications, and elective surgery is generally discouraged in this patient population 2.
• There are no guidelines for the preoperative risk assessment or perioperative management of subjects with pulmonary hypertension, but a multidisciplinary team approach is recommended 2, 3.
• Preoperative risk assessment should include evaluation of the severity of pulmonary hypertension, right ventricular function, and other patient-related factors 4, 5.
• Individualized preoperative risk assessment and optimization, as well as advanced perioperative planning, are essential to minimize complications 4, 6.

Key Considerations for Preoperative Assessment

• Evaluation of pulmonary hemodynamics and right ventricular function 2, 5
• Assessment of exercise performance and markers of PH severity 4
• Identification of patient-related risk factors, such as systemic hypotension and arrhythmias 5
• Optimization of PH and RV function prior to surgery 5

Perioperative Management Strategies

• Close monitoring of systemic blood pressure, oxygenation, and ventilation 5
• Prevention of systemic hypotension and acute elevations in pulmonary arterial pressure 5
• Use of vasopressors and pulmonary vasodilators as necessary 5
• Avoidance of exacerbating factors, such as fluid shifts and changes in the autonomic nervous system 5