Pulmonary Hypertension: Cardiac and Non-Cardiac Surgery
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Pulmonary Hypertension (PH) is a progressive disease caused by a wide spectrum of clinical conditions that is classified into five subgroups according to their similar clinical presentation, pathological findings, haemodynamic characteristics and treatment strategy. The PH is defined as a mean pulmonary arterial pressure mPAP >20 mm Hg or greater at exercise.
The World Health Organization has classified PH into 5 clinical subgroups:

  1. pulmonary arterial hypertension (PAH),
  2. PH due to left-sided heart disease,
  3. PH due to chronic lung disease,
  4. chronic thromboembolic PH (CTEPH), and
  5. PH with an unclear and/or multifactorial mechanism

Furthermore, recent guidelines from the 6th WSPH Task Force have added a detailed hemodynamic definition of PH which is the following.

Definition Characteristics Clinical Groups
PH mPAP > 20 mmHg All
Pre-capillary PH mPAP > 20 mmHg
PAWP ? 15 mmHg
PVR ? 3 Woods Units
 PAH
Thromboembolic disease
Lung disease
Post-capillary PH PAWP ? 15 mmHg
PVR < 3 Woods Units 		Left heart disease
Valvular disease

Patient management begins during the pre-operative period by optimizing RV preload, maintaining sinus rhythm, and avoiding hypoxia and hypercarbia.

PH medication is continued until the day of surgery and the common agents that using are: PDE-5 inhibitor(sildenafil), prostacyclins and endothelin receptors antagonist. In case that the patients are calcium responders their therapy should include calcium channels blockers.

We should keep in mind that the 1 and 1 receptors are downregulated due to RV pressure overload which leads to diminished inotropic response. On the other hand, little is known about the role of parasympathetic nervous system in RV dysfunction.

The intraoperative management of patients’ is implemented:

  1. all precipitating factors that predispose to further increase of PH, in case of arrhythmias we prefer amiodarone because ?-blockers are not well tolerate
  2. enhance oxygenation by increasing blood flow to ventilated areas, thus improving the ventilation-perfusion ratio.

As suggested by literature the combination of two vasodilators is far more beneficial, because we take into advantage their additive effects on the pulmonary vasculature by acting through different pathways. Furthermore, the administration Iloprost together with NO helps us progressively withdraw iNO avoiding rebound increase in PVR and MPAP.

Patients’ therapy is continued in the ICU and when patients become stable, the agents are de-escalated and extubating process begins. PH patients undergoing various types of surgery present a higher percentage of morbidity and mortality.

Also, most of the complications occur within 48 hours after surgery and RV dysfunction and acute respiratory failure are the major contributors to elevated mortality.
The management of patients with PH during the perioperative period in non-cardiac surgery based on the same principals as in cardiac surgery.
The anaesthetic approach follows the principles bellow:

  1. hemodynamic instability and increased PAP from mechanical ventilation. Furthermore, the epidural anesthesia provides postoperative pain control.
  2. agent of choice in case we choose balanced anaesthesia
    (Inhaled anesthetics block ATP-dependent potassium channels whose activation induces vascular relaxation, except Sevoflurane.

Laparoscopic procedures should be avoided because Trendelenburg positioning decreases lung compliance and FRC. Rapid insufflation of CO2 can cause vagal bradycardia, RV distension, impedes right coronary flow leading to cardiac arrest.

End-tidal CO2 elevation may require increasing minute ventilation or abdominal deflation to avoid the increased PVR, but there are not studies comparing laparoscopic versus open procedures in patients with PH, only the experts opinion.
In conclusion, our therapeutic management of patients with PH who undergo cardiac or non-cardiac operation should:

  1. Avoid all the conditions that provoke further PH increase
  2. Include administration all the anaesthetic agents with caution, titrating doses
  3. Preserve coronary arteries perfusion
  4. Inhaled pulmonary vasodilators
  5. For better results combine the vasodilators acting in two different pathways in order to take into advantage the additive effects

Patients with PH who undergo cardiac or noncardiac operations need special care, so more than the already existing studies are necessary in order to improve our perioperative approach.

Proposal: Development of an algorithm concerning perioperative anaesthetic management.

Registrations will close at 16:55 pm CEST (Rome time), secure NOW your seat!


IMPORTANT NOTICE
We are currently facing some technical problems. Therefore, if you want to register for the eSeminar on Monday, April 11, please send an email to eactaic@iameetings.sg with your email, name and surname.

The EACTAIC Education Committee has organised the seminar. It is supported by the Onassis Cardiac Surgery Centre, Athens (Greece)

What’s in it for me?

After participating in this webinar, you will better understand:

  • The guidelines and preoperative evaluation of patients presented with pulmonary hypertension.
  • The Therapeutic management in the OR and ICU
  • Perioperative management of patients with pulmonary hypertension who undergo non-cardiac surgery
Programme
Time Topic Speaker
18:00–18:10 1st Case Report: Patient with pulmonary hypertension undergoing cardiac surgery Dr A. Smyrli
18:10–18:20 Case Discussion —
18:20–18:30 Preoperative evaluation, definition, classification, and recent guidelines Dr A. Falara
18:30–18:40 Therapeutic management in the operating room Dr P. Ftikos
18:40–18:50 Therapeutic management in the ICU Dr M. Zouka
18:50–19:00 2nd Case Report: Patient with pulmonary hypertension undergoing non-cardiac surgery Dr E. Samara
19:00–19:10 Case Discussion —
19:10–19:30 QA, Open Discussion, and Wrapping up Dr F. Antoniou

Register Now

If you do not receive your Zoom link after 48 hours from registration,
please contact eactaic@iameetings.sg

IMPORTANT NOTICE

We are currently facing some technical problems. Therefore, if you want to register for the eSeminar on Monday, April 11, please send an email to eactaic@iameetings.sg with your email, name and surname.

Registrations will close at 16:55 pm CEST (Rome Time)

In order to register for this Event, please click here , then click on “click here to register”, “eactaic seminar”, and select “yes” to complete your registration.

Please use your full name and surname, since they will be used to issue the certificate of attendance.



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Event Details
10
Days
50
Hours
10
Min
00
Sec
Start Date
April 11, 2022 6:00 pm
End Date
April 11, 2022 7:30 pm
Status
Expired
Meet the speakers

Dr. Theofani Antoniou
Moderator

Dr. Anna Smyrli
Moderator

Dr. Panagiotis Ftikos
Speaker

Dr. Maria Zouka
Speaker

Dr. Areti Falara
Speaker

Dr. Evangelia Samara
Speaker

Opening, Mohamed El Tahan, Theofani Antoniou, April 11, 2022
https://youtu.be/AcX_9iK13SU 

Case Discussion: Patient with pulmonary hypertension undergoing cardiac surgery, A. Smyrli, Greece, April 11, 2022
https://youtu.be/iGNJrLtKusg

Preoperative evaluation, definition, classification, and recent guidelines, A. Falara, Greece, April 11, 2022
https://youtu.be/90P9alp_mxI

Therapeutic management in the operating room, P. Ftikos, Greece, April 11, 2022
https://youtu.be/DdYDr3aD2OQ

Therapeutic management in the ICU, M. Zouka, Greece, April 11, 2022
https://youtu.be/pjF38I1IP8Y

Second Case Discussion: Patient with pulmonary hypertension undergoing non-cardiac surgery, E. Samara, Greece, April 11, 2022
https://youtu.be/3oX7kED0ROk

QA, Open Discussion, and Wrapping up, M. El Tahan, Egypt, T. Antoniou, Greece, and Faculty, April 11, 2022
https://youtu.be/3J3W6P9qUoQ

Considering that 1mg of vasopressin=530 IU and the recommended safe dose for cardiac surgery pts is <0.1 IU/min, it is calculated to be 0.0025mcg/kg/min. We usually start at half of this dose and titrate it to the needs of the patient.

Yes,we do, at a cummulative dose of 50mcg/kg via a nebulizer apparatus.

Downregulation of ?1,?1 adrenergic and dopamine-1 receptors due to Rv pressure overload dictates the use of these agents in order to maintain myocardial perfusion, improve RV contractility, enhance venous return and increase cardiac output.Combination of all these drugs has an additive beneficial effect. The doses were titrated according to the continuously monitored PAP,SVO2,RV function (PA cath, TEE)

In severe PAH patients all agents are needed.We usually start with inhaled milrinone and iloprost monitoring PAP and RV function, then proceed to NO if necessary. Combination therapy offers additive benefit to PAP and RV function.

Yes we do, very slowly titrating doses according to BIS, usually 1-2mg/kg is enough for induction, without compromising haemodynamics.

It is advisable to do that in order to earlier achieve better therapeutic levels (avoid adherence on CPB tubing).It also has a protective effect on pulmonary vessels (reduced CBP inflammatory response) thus prevents worsening of PVR/PAP

Until RV function is stabilized, it is better for the patient to be sedated under controlled ventilation and analgesia to avoid an increase of RV work load.Gradual dosage lowering of pulmonary vasodilators and pressors, fluid balance are necessary as well.

will this change direction of practice and affect management? Yes it is mandatory in all PH cases in order to titrate pharmacological and fluid therapy in the OR and the ICU.

Until RV function is stabilized, it is better for the patient to be sedated under controlled ventilation and analgesia to avoid an increase of RV work load.Gradual dosage lowering of pulmonary vasodilators and pressors, fluid balance are necessary as well.

Optimizing all factors which might increase PAP and jeopardize RV function is difficult to achieve in few hours, adaptation is necessary.

The following references support that statement (Anesthesiology 121(5) Nov 2014:914-915, CritCareMed Jan2022 50(1):546, MedScape Nov 16, 2021)

These values were not mentioned because of the limited time of the presentation. Since they were continuously monitored,they were optimised accordingly to ensure adequate organ perfusion.RV function was moderate, comparable to the preoperative one.

We have used it in a limited number of pts for study purposes because it is very expensive. Also there is a risk of hypotension so an ICU bed with close monitoring would be necessary. Although we had good resultsthey can not be refered to as statisticaly significant.

Yes there was loe to moderate TVR (TAPSE=15mm, sRV=9cm/sec )

Yes, In every patient with a known history of pulmonary hypertension, that is admitted for evaluation prior cardiac surgery, an echo is done in order to reevaluate its condition and the efficacy of medical treatment.

A combination of inotrpic agents that act through different molecular pathways is possible and worthy of consideration in case of patients in need of inotropic support. The main goal of haemodynamic managment is to avoid exacerbation of preexisting pulmonary hypertension, support systemic blood pressure and myocardial contractillity.

The use of pulmonary vasodilators is generally contraindicated in case of severe left ventricular dysfunction, because their use decreases pulmonary artery pressure, increasing left ventricular preload.

The use of Pulmonary Artery Catheter(Swan-Ganz) allows the continous measurment of pulonary artery pressures itraoperatively and in the postoperative period. TOE permits the estimation of pulmonary artery pressure in presence of some degree of tricuspid regurgitation allowing at the same time the evaluation of right and left ventricular function. In case of severe pulmonary hypertension, combined use of Pulmonary Artery Catheter and TOE can be very helpful in the perioperative period.

All standart IV agents and volatile anaeshtetics can be used for the induction of anaesthesia.Histamine releasing factors (i.e. Atracurium) should be avoided. A balanced approach of anaesthesia characterized by haemodynamic stability is the best choise.

"A very interesting article regarding this issue is:Levosimendan in pulmonary hypertension and right heart failure.Pulmonary Circulation 2018; 8(3) 1–7 DOI: 10.1177/2045894018790905"

There is no evidence that IV induction or induction using volatile anaesthetics is related to better outcomes. All agents appropriately titrated can be used in order to ensure haemodynamic stability.

We do not use enoxamine. This drug is not available in Greece.

In our department we have never used volatile agents in the ICU.Despite this, there are studies published that highlight the use of volatile agents in the cardiac ICU ,but are not specific for PH patients.It is known that Sevoflurane causes bronchodilation ,improving oxygenation .In addition, studies have shown that Sevo in the ICU, after cardiac surgery has cardioprotective effect, as it reduces the serum troponin levels , in comparison to iv agents.It also improves delirium.So it would be a challenge to use volatile agents in Icu in the future and examine their effect.

We usually take the PAC out 24-48 hours after extubation and when we are sure that the patient is stable and responds well to treatment.There are no guidelines in our ICU on that, and we customize our practice to the patient.We are always careful for infection arrhythmias or other complications but so far we have never faced a major one

This was obviously a misunderstanding. ASA warns against "exsessive" use of oxygen, in total agreement with your first sentence, not against O2.

Not really, non-cardiac anesthesiologists are not familiar with its use yet.

This was a cancer procedure and there was a concern that if ASD was first repaired, by the time the patient would be fit for his thoracic surgery the tumor would be inoperable.

This was also an idea that came up, but would also very much delay the thoracic procedure, due to delays related with bureaucratic reasons in country of residence. Again, the concern was that the tumor would be inoperable by then.

For an elective surgery, and if he did not have the aortic stenosis, would basically apply all recommendations given by the literature so far. Would timely switch to non- enteral pulmonary vasodilators, continuing intraoperatively. Would also proceed with RA/PNB, if applicable. In case GA was required, would monitor with both PAC and TOE. Use of vasopressors as needed and fluid monitoring. Postoperatively, ICU monitoring to wean off the non-enteral agents and return to oral medication. For the second part of your question, I believe you meant for cardiac surgery, as this was a non- cardiac surgery at first place. For cardiac surgery, would have a similar preoperative optimization and his ASD would be also addressed intraoperatively.

I have found only a few studies investigating the liability of PAC during one lung ventilation, most of them conducted on animals. Clinical significance in changes was found to be minor. Additionally, the trends, combined with the rest of the monitoring can offer guidance. All values mentioned during the presentation were obtained during two lung ventilation.

No studies compare GA to RA in PH patients at the moment. However, with the existing evidence, literature agrees on RA when applicable.

No studies have compared laparoscopic to open approach in PH patients yet. However, since laparoscopic surgery is associated with speeder recovery and less postoperative pain, whereas not all procedures require positions to hemodynamically affect the patient, the technique is not considered off the table. Literature, however, advises on immediate conversion to open approach when necessary.

Thank you for this very interesting question. I do not think there is one answer that fits all, but we are talking about a non- elective case, and basically low risk patients regarding their PH, since they are asymptomatic. However, a thorough preoperarive medical history, a physical examination and the standard preoperative checking would reveal the patients to be further screened.

No studies compare GA to RA in PH patients at the moment. However, with the existing evidence, literature agrees on RA when applicable. Nevertheless, anxiety control should be easier addressed than the consenquences of Positive Pressure Ventilation.

The Onassis Cardiac Surgery Center is the premier cardiovascular surgery and interventional cardiology hospital in Greece, certified with ISO 9001:2015. It provides a complete spectrum of services in cardiac surgery and cardiology for all forms of acquired and congenital heart disease, including heart and lung adult transplantations. Its clinical results are comparable to those of the best centers in Europe and the USA

Among patients with RV dysfunction as a result of pressure overload, precapillary PH and left-sided heart failure are the most common etiologies. Effective strategies to optimize cardiopulmonary hemodynamics and support RV function are paramount. If pharmacological therapies are maximized but fail to stabilize the patient with RV failure, mechanical support should be considered. RVAD insertion is deemed necessary in case the RV can not provide adequate volume to LVAD even after maximizing the pharmacological approach

The de-escalation from MCS should become on a daily basis by evaluating the cardiac function with TOE and hemodynamics. According to the patient's vitals gradually reduce pump speed by 0.5 L/min decrements to 2 L/min, optimizing simultaneously the inotropic and vasopressor support. In the case, that hemodynamics and echo study reveal improvement of these parameters we should start de-escalating the patient from temporary MCS support

We rarely use implella in our patients

Optimal coupling occurs when the maximum stroke work is achieved with the minimum cardiac oxygen consumption. Pharmacological and fluid management aims at utilizing myocardial energy reserves in order to optimize LV preload and RV contractility. Thus the heart can provide adequate output without elevating its metabolic demand. TAPSE/systolic PAP ratio has been considered a valid index for the noninvasive evaluation of RV–arterial coupling.

contractility in order to provide suboptimal stroke work, but for higher efficiency.

The administration of a combination of inhaled pulmonary vasodilators acting through different pathways, for example, PDE5 and prostenoid inhalers, help RV function in a such away that the RV could provide adequate CO to LVAD which is desirable.