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Perioperative approach to precapillary pulmonary hypertension in non-cardiac non-obstetric surgery

Debabrata Bandyopadhyay, Christopher Lai, Juan N. Pulido, Ricardo Restrepo-Jaramillo, Adriano R. Tonelli, Marc Humbert
European Respiratory Review 2021 30: 210166; DOI: 10.1183/16000617.0166-2021
Debabrata Bandyopadhyay
1Center for Advanced Lung Disease and Lung Transplant, University of South Florida – Tampa General Hospital, Tampa, FL, USA
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  • ORCID record for Debabrata Bandyopadhyay
Christopher Lai
2Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France
3Assistance Publique Hôpitaux de Paris, Service de médecine intensive – réanimation, Hôpital Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France
4Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Juan N. Pulido
5Dept of Anesthesiology and Critical Care Medicine, Swedish Medical Center, Seattle, WA, USA and US Anesthesia Partners – Washington, Seattle, WA, USA
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Ricardo Restrepo-Jaramillo
1Center for Advanced Lung Disease and Lung Transplant, University of South Florida – Tampa General Hospital, Tampa, FL, USA
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Adriano R. Tonelli
6Dept of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
7Pathobiology Division, Lerner Research Institute, Cleveland Clinic, OH, USA
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Marc Humbert
3Assistance Publique Hôpitaux de Paris, Service de médecine intensive – réanimation, Hôpital Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France
4Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
8Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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  • For correspondence: marc.humbert@aphp.fr
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  • FIGURE 1
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    FIGURE 1

    Factors worsening pulmonary artery pressure and consequent right ventricular dilatation/ dysfunction in the perioperative period. CO: cardiac output; NTPE: non-thrombotic pulmonary embolism; PAP: pulmonary artery pressure; PE: pulmonary embolism; PPV: positive pressure ventilation; PVR: pulmonary vascular resistance; RV: right ventricle; SBP: systolic blood pressure.

  • FIGURE 2
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    FIGURE 2

    Suggested intraoperative monitoring and interventions in pulmonary hypertension patients [30, 49]. BB: beta blocker; CCB: calcium channel blocker; CI: cardiac index; CTEPH: chronic thromboembolic pulmonary disease; FIO2: fractional inspired oxygen; FRC: functional residual capacity; iNO: inhaled nitric oxide; MAP: mean arterial pressure; mPAP: mean pulmonary artery pressure; PAC: pulmonary artery catheter; PCO2: carbon dioxide tension; PVR: pulmonary vascular resistance; PEEP: positive end expiratory pressure; RAP: right atrial pressure; RV: right ventricle; SpO2: oxygen saturation; TCI: target controlled infusion; TEE: transoesophageal echocardiogram; VT: tidal volume.

Tables

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  • TABLE 1

    Studies showing the prevalence of perioperative complications after non-cardiac surgery in pulmonary hypertension (PH) patients

    Authors, year [ref.]Study typeNPH diagnosisAetiology of PHGAMajor surgeryMortalityMorbidity
    Ramakrishna et al. 2005 [34]Retrospective no control145TTE or RHCGroup 1 45%
    Group 3 19%
    Group 4 8%
    100%79%7%42%
    Minai et al. 2006 [36]Retrospective no control28#RHCGroup 1 100%79%86%18%19%
    Lai et al. 2007 [37]Retrospective no control62TTEGroup 1 18%
    Group 2 21%
    Group 3 21%
    58%65%9.7%24%
    Price et al. 2010 [29]Retrospective no control28RHCGroup 1 72%
    Group 4 28%
    50%57%7%29%
    Memtsoudis et al. 2010 [38]Retrospective 1:3 matching with no-PH3543Not specifiedNANA100% (THR/TKR)2.4% (versus 0.9% in no-PH)NA
    Kaw et al. 2010 [33]Retrospective controlled96RHCGroup 1 12%
    Group 2 40%
    Group 5 48%
    100%48%1%28%
    Meyer et al. 2013 [32]Prospective no control114RHCGroup 1 100%82%69%3.5%6.1%
    Seyfarth et al. 2015 [39]Retrospective no control31RHCGroup 1 74%
    Group 3 10%
    Group 4 16%
    77%100%3%25%
    Smilowitz et al. 2019 [40]Retrospective controlled3500Variable¶Group 1 100%NAAll types8.3%12.9%
    Deljou et al. 2019 [41]Retrospective no control196RHCGroup 1 74%
    Group 3 14%
    Group 4 13%
    100%45%3%27%

    GA: general anaesthesia; NA: not available; RHC: right heart catheterisation; TTE: transthoracic echocardiography; THR: total hip replacement; TKR: total knee replacement. #: N=21 patients underwent 28 procedures. ¶: 149 (4.3%) patients had RHC, others were reported PAH.

    • TABLE 2

      Risk factors for perioperative morbidity and mortality in pulmonary hypertension patients

      Patient characteristics
      PAH >mixed or postcapillary PH [33, 58]
      History of PE, coronary artery disease, OSA or chronic renal insufficiency [28, 30, 59]
      WHO functional class III and IV [41]
      ASA class>II [30]
      6MWD <400 m [30]
      ECG: right-axis deviation [30]
      NT-proBNP≥300 pg·mL−1 [41]
      TTE: RV hypertrophy, RV index of myocardial performance ≥0.75, RVSP/SBP ≥0.66 [34, 59, 60]
      Pulmonary haemodynamics: mPAP >45 mmHg, elevated RAP [61] or sPAP >70 mmHg,
      CI <2 L·min−1·m−2 [30]
      Anaesthesia attributes
      Duration of anaesthesia >3 h [29, 58]
      Perioperative use of vasopressors [34, 60]
      Intermediate to high-risk surgery [41]
      Emergency procedures [32, 60].

      6MWD: six-minute walk distance; ASA: American Society of Anesthesiology; CI: cardiac index; ECG: electrocardiogram; mPAP: mean pulmonary artery pressure, NT-proBNP: N-terminal pro-brain natriuretic peptide; OSA: obstructive sleep apnoea; PAH: pulmonary arterial hypertension; PE: pulmonary embolism; PH: pulmonary hypertension; PVR: pulmonary vascular resistance; RAP: right atrial pressure; RV: right ventricle; RVSP: right ventricle systolic pressure; sPAP: systolic pulmonary artery pressure; SBP: systolic blood pressure; TTE: transthoracic echocardiography; WHO: World Health Organization.

      • TABLE 3

        Effects of anaesthetic agents, vasopressors and inotropes on pulmonary vasculature and right ventricle function [42, 47, 96, 97, 100, 101]

        AgentsmPAPPVRRV contractility
        Anaesthetic agents
         Isoflurane↓↔↓↓
         Desflurane↓↔↓↓
         Sevoflurane↓↔↓↓
         Nitrous oxide↑↑↑↑↓
         Thiopental sodium↔↔↓
         Etomidate↔↔↔
         Ketamine↑↔/↑↓
         Propofol↓↓↓↓
         Fentanyl/sufentanil↔↔↔
         Remifentanil↔↔↔
        Vasopressors
         Norepinephrine↑↑↑
         Epinephrine↑↑↑
         Phenylephrine↑↑↓↓
         Vasopressin↓↓↔
        Inotropes
         Dobutamine↔↑, ↔, ↓#↑↑
         Milrinone↔↓↑↑
         Levosimendan↓↓↑

        ↑ Increase; ↑↑ marked increase; ↓ reduction; ↓↓ marked reduction; ↔ no effect. mPAP: mean pulmonary arterial pressure; PVR: pulmonary vascular resistance; RV: right ventricle. #: Conflicting data about the effect of dobutamine in PVR. Dobutamine decreases PVR at low dose (<5 µg·kg−1·min−1), no effect at median dose of 10 µg·kg−1·min−1 and increases PVR at higher dose, more than 15 µg·kg−1·min−1 [47, 102–104].

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        Perioperative approach to precapillary pulmonary hypertension in non-cardiac non-obstetric surgery
        Debabrata Bandyopadhyay, Christopher Lai, Juan N. Pulido, Ricardo Restrepo-Jaramillo, Adriano R. Tonelli, Marc Humbert
        European Respiratory Review Dec 2021, 30 (162) 210166; DOI: 10.1183/16000617.0166-2021

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        Perioperative approach to precapillary pulmonary hypertension in non-cardiac non-obstetric surgery
        Debabrata Bandyopadhyay, Christopher Lai, Juan N. Pulido, Ricardo Restrepo-Jaramillo, Adriano R. Tonelli, Marc Humbert
        European Respiratory Review Dec 2021, 30 (162) 210166; DOI: 10.1183/16000617.0166-2021
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        • Article
          • Abstract
          • Abstract
          • Introduction
          • Classification of PH
          • PAH medications
          • Haemodynamic pathophysiology of PH
          • Anaesthesia in patients with PH
          • Preoperative evaluation of PH patients
          • Intraoperative management of PH
          • Special surgical populations
          • Postoperative care of patients with PH
          • Supplementary material
          • Footnotes
          • References
        • Figures & Data
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        • Pulmonary vascular disease
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