Implementation of a Pulmonary Arterial Hypertension (Pah) Preoperative Algorithm for Noncardiac Surgery

1Cleveland Clinic, Cleveland, OH
2MetroHealth Medical Center, Cleveland, OH

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 154


Noncardiac surgery in patients with pulmonary arterial hypertension (PAH) is associated with a morbidity of 42% and a mortality of 7%. The most important pathophysiologic consideration is the effect of increased pulmonary vascular resistance (PVR) on the right ventricular function. PAH has a progressive nature; initially it is caused by a vasoconstrictor process that reverses easily with vasodilator therapy, but then it progresses toward significant vascular fibrosis with irreversible changes with limited or no effect of vasodilator therapy. The main predictors of morbidity and mortality in these patients include: history of pulmonary embolism, NYHA class II, intermediate‐ to high‐risk surgery, surgery duration > 3 hours, right axis deviation, right ventricular hypertrophy, right ventricle systolic pressure (RVSP) > than SBP, and intraoperative vasopressor use.


To implement a preoperative algorithm to identify patients with PAH undergoing noncardiac surgery for appropriate stratification and optimization and minimize perioperative morbidity and mortality.


A complete history and physical examination is performed with special attention to signs and symptoms of right ventricular dysfunction: dyspnea on exertion (DOE), chest pain, exertional desaturation, right heart failure (large jugular V wave, peripheral edema, and hepatomegaly), syncope, loud P2, and systolic murmur LLSB. The initial preoperative tests include: EKG, chest roentgenogram, and echocardiography. The patient is referred to the pulmonary vascular consult service if she or he has: (1) an established diagnosis of PAH; (2) RVSP > 50 mm Hg on echocardiogram; (3) RVSP 40–50 with DOE, right ventricular dilatation, or dysfunction (see table). The patient is streamlined to surgery if RVSP < 50, is asymptomatic, and has normal RV function. In the immediate perioperative period chronic PAH therapy should be continued. Patients on parenteral prostacyclines may be maintained on their baseline infusion, although they may be switched to intravenous prostacycline perioperatively (e.g., epoprostenol). All patients on chronic anticoagulation should be bridged to intravenous heparin.


This algorithm will permit the preoperative identification and optimization of patients with PAH at higher risk of postoperative morbid and mortality.


M. Auron ‐ none; A. Kumar ‐ none; M. Y. Duran‐Castillo ‐ none; G. Heresi‐Davila ‐ none; C. Vlah ‐ none; R. Dweik ‐ none

To cite this abstract:

Auron M, Kumar A, Duran‐Castillo M, Heresi‐Davila G, Vlah C, Dweik R. Implementation of a Pulmonary Arterial Hypertension (Pah) Preoperative Algorithm for Noncardiac Surgery. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 154. Journal of Hospital Medicine. 2011; 6 (suppl 2). Accessed March 31, 2020.

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