Pulmonary Arterial

Hypertension: An
Anesthetic Approach
Overview
● Elevated mean pulmonary arterial pressure ≥25 mmHg at rest (normal is
14∓ 3)
● Classification
○ Group 1 – Pulmonary arterial hypertension (PAH)
○ Group 2 – PH due to left heart disease
○ Group 3 – PH due to chronic lung disease and/or hypoxemia
○ Group 4 – PH due to chronic thromboembolic pulmonary hypertension
○ Group 5 – PH due to unclear multifactorial mechanisms
Pathophysiology
● Acute: Increased PVR→ Increased in R ventricular afterload (i.e. end diastolic
volume)→ Reduced RV EF and decreased stroke volume of R ventricle
● Chronic: Increased PVR→ Progressive systolic pressure overload of RV→ Dilatation
and hypertrophy→
○ 1) RV dysfunction→ Reduced RV EF→ Reduced volume available for LV filling→ Reduced
CO and arterial pressure
○ 2) RV hypertrophy causes interventricular septal bowing reducing LV volume→ Reduced
end diastolic LV volume→ Reduced CO and arterial pressure
● Decreased SVR in anesthesia normally
● Hypotension reduces coronary perfusion pressure, exacerbating R heart failure; RV
normally receives coronary blood flow in diastole and systole but if R ventricular
systolic pressure is equal to or higher than systemic pressure coronary blood flow
will be dramatically decreased; can also become limited during diastole if RV end
diastolic pressures are increased
Pathophysiology cont.
● Patent Foramen Ovale
○ Up to 30% of adults have a patent foramen ovale
○ If R atrial pressure exceeds L atrial pressure a R→ L shunt will form→ Systemic oxygen
desaturation
Clinical Manifestations
● Inability to increase CO during exercise
○ Exertional dyspnea, lethargy, and fatigue
● Exertional angina (coronary hypoperfusion)
● Exertional syncope
● Peripheral edema
● Anorexia or RUQ abdominal pain (portal congestion)
● Widened, split S2
● Elevated JVP
● RBB on EKG
● Tricuspid regurgitation or Pulmonic regurgitation
● Hepatomegaly, ascites, edema
Perioperative Anesthetic Considerations
● Prevention of R Heart Failure
○ Hypercapnia: Increased PVR + R ventricular afterload
○ Hypoxemia: Pulmonary vasoconstriction; tx with FiO2
○ Maintenance of MAP→ Low MAP results in decreased coronary perfusion further
exacerbating R heart failure
● Laparoscopic Operations:
○ Carbon dioxide pneumoperitoneum→ hypercapnia + increased intra-abdominal
pressures
● Positioning: Trendelenburg
○ Increased venous return to RA→ Overload and R heart failure
○ Increased intra abdominal pressures transmitted across diaphragm→ Greater pressure
required to expand lung
● PEEP: Elevates intrathoracic pressure→ Decreased preload and increased
afterload; try to minimize
Perioperative Anesthetic Considerations cont.
● Propofol and Ketamine
○ Conflicting studies in in-vitro models and dogs; See vasoconstriction in some cases and
vasodilatation in others
○ Propofol is used as induction agent in pts with pulmonary HTN without problems
○ Demonstrates that the reactivity of the pulmonary vascular bed is mediated by the
integration of several systems
● Desflurane
○ Potentiates pulmonary vasoconstrictor response to adrenergic stimulation
● Isoflurane
○ Bronchodilator
○ Attenuates B2 activity on pulmonary vasculature
○ Attenuates pulmonary vasoconstrictive response to hypotension
● Sevoflurane
○ Bronchodilator, though not as potent as Isoflurane
Perioperative Anesthetic Treatment
● Dobutamine
○ B-adrenergic agent used to treat hypotension
○ Causes pulmonary vasodilation
● Nitric Oxide/Prostacyclin
○ Reduces pulmonary vascular resistance while augmenting cardiac output
○ Act via different mechanisms so effects are additive
● Norepinephrine and Phenylephrine
○ Vasoconstrictors
○ Norepi also has inotropic effects
Preoperative Considerations
● ECG
○ R ventricular hypertrophy, R atrial enlargement
● Right heart catheterization
○ Degree of pulmonary HTN
○ Central venous pressure
○ Cardiac index
● Echocardiogram
○ R ventricular hypertrophy, dilatation of the right heart chamber with impairment of left
ventricular filling, and paradoxical motion of the interventricular septum.
● CXR
○ Enlarged pulmonary arteries
● ABG
Postoperative Considerations
● Pts with pulmonary HTN often die suddenly during first postoperative
days
○ Etiology unclear: pulmonary vasospasm, progressive increase in pulmonary vascular tone,
pulmonary thromboembolism, cardiac arrhythmia, fluid shift
● Postoperative management is similar to intraoperative management
○ Maintain MAP
■ Maintain euvolemia
■ Support with pressors if needed
○ Avoid hypoxemia and hypercapnia
■ Support ventilation with judicious opioid management, consider local anesthetic
and nerve blocks
■ Support oxygenation with FiO2
References
1. Blaise, Gilbert, David Langleben, and Bernard Hubert. "Pulmonary Arterial Hypertension Pathophysiology and Anesthetic
Approach." The Journal of the American Society of Anesthesiologists 99.6 (2003): 1415-1432.
2. Ortega, Rafael, and Christopher W. Connor. "Intraoperative Management of Patients with Pulmonary Hypertension."
Advances in Pulmonary Hypertension 12.1 (2013).
3. Miller, Ronald D., and Manuel Pardo. Basics of Anesthesia E-Book. Elsevier Health Sciences, 2011.

4. Dezube, Rebecca, Traci Housten, and Stephen C. Mathai. "Postoperative Care of the Patient With Pulmonary
Hypertension." Advances in Pulmonary Hypertension 12.1 (2013).