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Advances in PH Journal

Managing PAH in the Perioperative Setting, Spring 2013 (Vol 12, No 1)
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  • Preoperative Considerations in Patients With Pulmonary Hypertension: Your Patient Needs Surgical Clearance
    Patients with pulmonary arterial hypertension (PAH) are at increased morbidity and mortality risk when facing the need to undergo surgical interventions. The most common complications include those arising from right ventricular (RV) failure and respiratory failure - not surprising given the complex cardiopulmonary pathophysiology of this disease. While data are limited regarding the optimal preoperative approach to these patients, it is imperative to focus on the following key components: ensuring or establishing the patient's World Health Organization (WHO) classification pulmonary hypertension (PH) group or subgroup; assessing the status and stability of RV function; optimizing the treatment regimen; and communicating a management plan for the intra- and perioperative management to all members of the interdisciplinary clinical team. This article will focus on each of these steps in the preoperative algorithm, highlighting the need for further studies in this area.
  • Intraoperative Management of Patients with Pulmonary Hypertension
    Patients with pulmonary hypertension are some of the most challenging for an anesthesiologist to manage. Pulmonary hypertension in patients undergoing surgical procedures is associated with high morbidity and mortality due to right ventricular failure, arrhythmias, and ischemia leading to hemodynamic instability, and intra- and postoperative hypoxia. Considering the challenges that these patients pose in the perioperative period, it is critical for anesthesiologists, surgeons, and other patients who care for these patients to be well versed in managing pulmonary hypertension. The purpose of this article is to review the anesthetic considerations that pertain to patients with pulmonary hypertension in the perioperative period, with particular emphasis on the choice of anesthesia, the relative risks of moderate sedation and general anesthesia, and the most recent intraoperative monitoring recommendations.
  • Post-operative Care of the Patient With Pulmonary Hypertension
    Case: SH is a 46-year old woman with idiopathic pulmonary arterial hypertension (IPAH) (World Health Organization [WHO] Group 1), New York Heart Association functional class (NYHA FC) I, treated with bosentan and sildenafil as well as with anticoagulation. She was diagnosed with IPAH 10 years prior and her most recent right heart catheterization (RHC) showed a right atrial pressure of 7 mm Hg, mean pulmonary artery pressure (mPAP) of 48 mm Hg, cardiac output of 5.3 L/min, and pulmonary vascular resistance (PVR) of 7.1 Wood units. She was transferred to our intensive care unit with vaginal bleeding significant enough to cause systemic hypotension associated with cardiac troponin leak and requiring multiple units of transfusions. Uterine artery embolization was attempted by interventional radiology at our institution, but the patient continued to have significant bleeding postprocedure. The patient ultimately was urgently taken to the operating room and underwent dilation and curettage while receiving general anesthesia. The patient tolerated the procedure well, was extubated, and transferred to the intensive care unity on 100% oxygen delivered by face mask. The surgical team requests consultation regarding postoperative management. What advice would you give?
  • Pulmonary Hypertension Roundtable: Pulmonary Roundtable – Bariatric Surgery and the PAH Patient
    As guest editor of this issue on perioperative issues in PAH patients, Sean Studer, MD, MSc, convened a group of experts to discuss the implications of bariatric surgery for the pulmonary hypertension patient. Given the prevalence of obesity and its sequelae related to PH patients, it is not an uncommon topic. The approach to patient counseling, minimizing surgical risks, and working with the interdisciplinary team were addressed among the wide range of topics by clinicians on the front lines. Taking part in the conversation were Michael Mathier, MD, Assistant Professor of Medicine, Director, Pulmonary Hypertension Program, and Associate Director, Cardiovascular Fellowship Program at the University of Pittsburgh Medical Center; Dana P. McGlothlin, MD, Medical Director of Combined Heart-Lung Transplantation and Mechanical Circulatory Support, Medical Director of the Cardiac Intensive Care Unit, and Associate Director of the Pulmonary Hypertension Program at the University of California, San Francisco; Ramesh C. Ramanathan, MD, is a surgeon specializing in bariatric surgery at the University of Pittsburgh Medical Center. Deborah J. Levine, MD, Associate Professor, Pulmonary Disease and Critical Care Medicine, Director, Pulmonary Hypertension Clinic, University of Texas Health Science Center, San Antonio, added comments from the pulmonary perspective to the transcript of the discussion.
  • PHPN: Getting Ready for Surgery: Checklist for the Pulmonary Hypertension Patient
    Pulmonary hypertension (PH) patients who undergo surgical procedures are at increased risk for complications.1 Patients need a comprehensive medical te
  • Ask the Expert: Perioperative Management of Pulmonary Hypertensive Crisis
    Read about the management of pulmonary hypertensive crisis in the perioperative setting. Pulmonary hypertensive crisis is characterized by an acute rise in pulmonary pressures, causing pressure overload of the right ventricle and decreased cardiac output.