Perioperative management of pulmonary hypertension remains one of the most challenging scenarios during cardiac surgery. It is associated with high morbidity and mortality due to right ventricular failure, arrhythmias, myocardial ischemia, and intractable hypoxia.

Therefore, this review article is intended toward the anesthetic considerations in the perioperative period, with particular emphasis on the selection of technique and choice of anesthesia with maintenance, anesthetic drugs, and the recent intraoperative recommendations for prevention and treatment of pulmonary hypertensive crisis.

Cardiac anesthesiologists routinely encounter pulmonary hypertension (PH) in the perioperative period. Anesthesia administration in this subset of patients is a challenging task due to hyperreactive airway and risk of right ventricular (RV) failure.

However, with the advent of innovative treatments and advanced hemodynamic monitoring, successful management of these patients is a reality nowadays. The functional status and life expectancy of patients with this condition have significantly increased; so, these patients are likely to encounter noncardiac surgical procedures too.

The anesthetic management of such patients requires a thorough understanding of the etiology, pathophysiology, type, and severity of PH along with the nature of the surgical procedure.

Preoperative Assessment

The preoperative evaluation of these patients includes assessment of functional state, the severity of the disease, and type of surgery proposed. A detailed history of symptoms including dyspnea, chest pain, fatigue, and syncope should be elicited. NYHA functional class predicts survival in these patients.

The severity of disease is also suggested by symptoms of low cardiac output, including metabolic acidosis, hypoxia, and syncope which is a poor prognostic sign. Preoperative investigations include routine blood tests, chest radiography, electrocardiography, echocardiography, pulmonary function tests (PFTs) including blood gas analysis, and right heart catheterization.

General Anesthesia

Pro-brain natriuretic peptide level is an independent predictor for postoperative cardiac mortality in patients undergoing noncardiac surgery. General anesthesia is preferred for all cardiac surgery patients in view of smooth induction and maintenance although few anesthesiologists prefer to administer regional anesthesia in selected cases.

PH and cardiac surgery are associated with significant morbidity and mortality and a reduction in quality of life. However, perioperative management has become more effective due to a deeper understanding of the disease and newer therapeutic interventions. Advanced monitoring in the form of intraoperative TEE to assess biventricular dimensions and contractility, greatly facilitates the conduct of anesthesia.


Nevertheless, selective pulmonary vasodilation by inhalation modality should be available intraoperatively, in addition to invasive hemodynamic monitoring. Continuous postoperative monitoring and adequate analgesia should be taken care.

Successful perioperative management of such patients requires a thorough assessment, careful planning, and multispecialty involvement of anesthesiologist, surgeon, cardiologists, and pulmonologists, which allow for the best possible outcomes.