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Risk Assessment of Pulmonary Hypertension in Noncardiac Surgery: More Than a Right Heart Catheterization?

2020; Elsevier BV; Volume: 34; Issue: 6 Linguagem: Inglês

10.1053/j.jvca.2019.12.038

1532-8422

Christine Choi, Timothy M. Maus,

Cardiac Arrhythmias and Treatments

IN 1901, DR. ABEL AYERZA from the University of Buenos Aires gave a lecture on a unique pulmonary syndrome with symptoms of dyspnea, cyanosis, and polycythemia with an etiology related to pulmonary artery sclerosis. Twenty-four years later, the disease was described fully and termed Ayerza's disease, which subsequently became the entity we are familiar with, pulmonary hypertension (PH). Subsequent decades saw further examination of the disease, including its link to left heart failure and subsequent right heart failure.1Brenner O. Pathology of the vessels of the pulmonary circulation.Arch Intern Med. 1935; 56: 976Crossref Scopus (12) Google Scholar However, it was the epidemic outbreak of aminorex-induced PH in the 1960s that prompted worldwide attention and research into the disease process, leading to the first World Health Organization (WHO) symposium in Geneva on PH.2Gurtner H.P. Aminorex pulmonary hypertension.in: Fishman A.P. The pulmonary circulation, normal and abnormal. University of Pennsylvania Press, Philadelphia, PA1990: 397-411Crossref Google Scholar Five subsequent WHO symposiums have refined the nomenclature and classification system in addition to diagnostic criteria used for PH. Identifying the increased morbidity and mortality of patients with PH from a variety of mechanisms has been instrumental to awareness and treatment of this disease. Additionally, identification of operative risk in these patients is a key step in their successful management. In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Deljou et al. continue to delineate the operative risk of this patient population and build upon their institutions’ prior published experience with patients with PH undergoing noncardiac surgery, further identifying and clarifying perioperative morbidity and mortality.3Deljou A. Sabov M. Kane G.C. et al.Outcomes after noncardiac surgery for patients with pulmonary hypertension: A historical cohort study.J Cardiothorac Vasc Anesth. 2020; 34: 1506-1513Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar It has been well established that PH is a predictor of mortality and morbidity in those patients undergoing cardiac procedures. Several case reports, small case series, and retrospective data analyses have established this, including one of the early case reports by Kuralay that demonstrated the detrimental impact of PH on patients undergoing coronary artery bypass grafting requiring cardiopulmonary bypass.4Kuralay E. Demírkiliç U. Öz B.S. et al.Primary pulmonary hypertension and coronary artery bypass surgery.J Card Surg. 2002; 17: 79-80Crossref PubMed Scopus (26) Google Scholar Reich et al. showed preoperative mean pulmonary artery pressure > 30 mmHg and post-cardiopulmonary bypass diastolic pulmonary artery pressure > 20 mmHg to be predictors of mortality.5Reich D.L. Bodian C.A. Krol M. et al.Intraoperative hemodynamic predictors of mortality, stroke, and myocardial infarction after coronary artery bypass surgery.Anesth Analg. 1999; 89: 814Crossref PubMed Google Scholar This study also revealed that PH was a predictor of significant postoperative morbidity, including myocardial infarction. In an attempt to improve management, Beck et al. described the use of inhaled nitric oxide to reduce mean pulmonary artery pressure leading to improved cardiac index and systemic blood pressure, indicating inhaled nitric oxide as a useful adjunct in treating PH in patients undergoing cardiac surgery.6Beck J.R. Mongero L.B. Kroslowitz R.M. et al.Inhaled nitric oxide improves hemodynamics in patients with acute pulmonary hypertension after high-risk cardiac surgery.Perfusion. 1999; 14: 37-42Crossref PubMed Scopus (47) Google Scholar Although there have been several major studies focusing on the effects of PH on patients undergoing cardiac surgery, there has been a relative paucity in data regarding the role of PH in patients undergoing noncardiac surgery. Rodriguez and Pearl described one of the first case reports of a patient with severe PH successfully undergoing a major noncardiac surgical procedure (open abdominal aortic aneurysm repair) with the use of nitroglycerin as a pulmonary vasodilator.7Rodriguez R.M. Pearl R.G. Pulmonary hypertension and major surgery.Anesth Analg. 1998; 87: 812-815Crossref PubMed Google Scholar Earlier data from the same institution as Deljou et al. established PH to be an independent predictor of mortality and morbidity.8Ramakrishna G. Sprung J. Ravi B.S. et al.Impact of pulmonary hypertension on the outcomes of noncardiac surgery.J Am Coll Cardiol. 2005; 45: 1691-1699Crossref PubMed Scopus (287) Google Scholar Although they did not show causality, the study was significant in that it was one of the first larger retrospective data analyses that showed substantial correlation between PH and adverse outcomes after noncardiac surgery. Lai et al. conducted one of the first prospective studies comparing postsurgical complication rates in patients with and without PH.9Lai H.C. Lai H.C. Wang K.Y. et al.Severe pulmonary hypertension complicates postoperative outcome of non-cardiac surgery.Br J Anaesth. 2007; 99: 184-190Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar Although the PH group did not have more intraoperative adverse outcomes compared to the control group, the PH group experienced significantly higher postoperative complications, including heart failure, delayed extubation, and in-hospital death. They also concluded that the urgency of surgery, presence of coronary artery disease, and pulmonary artery pressure levels predicted in-hospital mortality rates for PH patients, whereas the surgical risk level and presence of coronary artery disease served as an independent predictor of postoperative morbidity. Several other subsequent studies continued to display PH as a predictor of adverse outcomes including mortality.10Kaw R. Pasupuleti V. Deshpande A. et al.Pulmonary hypertension: An important predictor of outcomes in patients undergoing non-cardiac surgery.Respir Med. 2011; 105: 619-624Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar,11Price L.C. Montani D. Jais X. et al.Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension.Eur Respir J. 2010; 35: 1294-1302Crossref PubMed Scopus (92) Google Scholar Deljou et al. again confirmed that PH is a predictor of morbidity and mortality. However, their study went a step further to assess whether diagnostic tests specific to PH or cardiopulmonary hemodynamic parameters were predictive of perioperative outcomes, giving clinicians a qualitative and a quantitative tool to evaluate perioperative risks. They examined clinical parameters such as the 6-minute walk test, N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, WHO functional class, high versus low surgical risk, echocardiography parameters such as tricuspid annular plane systolic excursion, estimated right ventricular (RV) systolic pressure, RV strain, and preoperative right heart catheterization data. Among these parameters, WHO functional class, NT-proBNP, and high surgical risk were found to be independent predictors of postoperative complications. None of the commonly used hemodynamic parameters from right heart catheterization or echocardiographic parameters of RV function had correlation with increased perioperative complications. This is an interesting observation because clinicians may rely intuitively on right heart catheterization data and echocardiographic findings to assess the severity of PH or right heart function and subsequently correlate that with higher risk of perioperative complication. The authors do note the limitation of statistical power for some of these measurements. Despite this limitation of the study, the study is significant in that it provides clinicians with tangible quantitative measures, such as serum NT-proBNP and WHO functional status, and qualitative measures, such as high versus low operative risk, to assess the perioperative morbidity and mortality rates for those patients with PH undergoing a noncardiac surgical procedure. Furthermore, many of the complications that the group observed are not related necessarily to the pathophysiology of PH, such as sepsis, bleeding, delirium, and reoperation. Further study is necessary to evaluate the mechanism behind these complications. In conclusion, PH is a substantial risk factor that increases morbidity and mortality in patients undergoing noncardiac surgical procedures. Although further studies are warranted to investigate the exact pathophysiologic mechanism behind PH that raises these perioperative risks, recent studies demonstrate the risk that PH poses to patients and the vigilance needed in taking care of these patients in the immediate perioperative period. Furthermore, evidence of heart failure in patients with PH, such as an elevated NT-proBNP or poor WHO functional class level, can be used to stratify perioperative risks in our everyday practice. None. Outcomes After Noncardiac Surgery for Patients with Pulmonary Hypertension: A Historical Cohort StudyJournal of Cardiothoracic and Vascular AnesthesiaVol. 34Issue 6PreviewPulmonary hypertension (PH) is a substantial preoperative risk factor. For this study, morbidity and mortality were examined after noncardiac surgery in patients with precapillary PH. 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