Perioperative anesthesiological management of patients with pulmonary hypertension

Perioperative Management of an Obstetric Patient with Eisenmenger Syndrome and Pre-Eclampsia Using Milrinone

ABSTRACT

Pregnancy in a patient with pulmonary hypertension carries a high risk of mortality. It poses multiple problems in the management of pregnancy, labor, and postpartum, thereby emphasizing the need for a multidisciplinary team for a successful outcome. We describe the successful management of a case of Eisenmenger syndrome who developed pre-eclampsia during her 28 weeks of pregnancy. As far as our knowledge, this is the first case report that describes the use of milrinone in a parturient for a successful outcome.

Perioperative Anesthesia Management for Pregnant Mother with Multivalvular Heart Disease and Moderate Pulmonary Hypertension Who Underwent Caesarean Section, in Resource Limiting Area 2022: A Case Report

Introduction

As measured by a right heart catheterization, pulmonary hypertension is an increase in mean pulmonary arterial pressure of more than 25 mmHg at rest or more than 30 mmHg during exercise. Some of the cardiac heart conditions that may develop during pregnancy include severe mitral regurgitation and mild tricuspid regurgitation. Prior to delivery, pregnant patients with pulmonary hypertension and significant multivalvular heart disease need to undergo careful preoperative, multidisciplinary assessment, and anaesthetic planning to maximize cardiac function during the peripartum period and make informed decisions about the delivery mood and anaesthetic technique.

Case Presentation

A 30-year-old Para two Gravid three pregnant mother presented with chronic rheumatic heart disease, severe mitral regurgitation, moderate pulmonary hypertension, severe left atrial dilatation, mild aortic regurgitation, and mild tricuspid regurgitation scheduled for elective cesarean section. She had one previous cesarean section four years ago with an indication of fetal macrosomia. Her cardiac condition, however, was moderate mitral regurgitation, mild left atrial dilatation, mild pulmonary hypertension, and no tricuspid or aortic regurgitation. She had continuous follow-ups after diagnosis until now but has not taken any medication.

Conclusion

Anaesthesia management in a patient with severe mitral regurgitation, moderate pulmonary hypertension, severe left atrial dilatation, mild aortic regurgitation, and mild tricuspid regurgitation was challenging in resource limited area. Even if spontaneous delivery is recommended for the patients with cardiac findings, a cesarean delivery will need in the area where limited access to support it. Goal-directed perioperative management with multidisciplinary involvement helps the patient to have a good outcome.

General anaesthesia-related complications of gut motility with a focus on cholinergic mechanisms, TRP channels and visceral pain

General anesthesia produces multiple side effects. Notably, it temporarily impairs gastrointestinal motility following surgery and causes the so-called postoperative ileus (POI), a multifactorial and complex condition that develops secondary to neuromuscular failure and mainly affects the small intestine. There are currently limited medication options for POI, reflecting a lack of comprehensive understanding of the mechanisms involved in this complex condition. Notably, although acetylcholine is one of the major neurotransmitters initiating excitation-contraction coupling in the gut, cholinergic stimulation by prokinetic drugs is not very efficient in case of POI. Acetylcholine when released from excitatory motoneurones of the enteric nervous system binds to and activates M2 and M3 types of muscarinic receptors in smooth muscle myocytes. Downstream of these G protein-coupled receptors, muscarinic cation TRPC4 channels act as the major focal point of receptor-mediated signal integration, causing membrane depolarisation accompanied by action potential discharge and calcium influx via L-type Ca²⁺ channels for myocyte contraction. We have recently found that both inhalation (isoflurane) and intravenous (ketamine) anesthetics significantly inhibit this muscarinic cation current (termed mI _CAT) in ileal myocytes, even when G proteins are activated directly by intracellular GTPγS, i.e., bypassing muscarinic receptors. Here we aim to summarize Transient Receptor Potential channels and calcium signalling-related aspects of the cholinergic mechanisms in the gut and visceral pain, discuss exactly how these may be negatively impacted by general anaesthetics, while proposing the receptor-operated TRPC4 channel as a novel molecular target for the treatment of POI.

A Literature Review on the Anesthetic Management of Pulmonary Arterial Hypertension in Non-cardiothoracic Surgery

Pulmonary hypertension (PH) is characterized by narrowing small pulmonary arteries, escalating pulmonary vascular resistance, and affecting the entire cardiovascular system. Pulmonary arterial hypertension (PAH) represents a subgroup of PH and typically affects one in 20,000 individuals. When treating individuals with PAH for non-cardiothoracic surgery, anesthetic management strategies should be tailored to the individual's specific needs. This literature review assessed the anesthetic management of PAH in non-cardiothoracic surgery. Electronic databases such as PubMed, ScienceDirect, Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane, and Google Scholar were searched using relevant keywords related to PAH, noncardiac surgery, and anesthesia. Reference lists and author names were also investigated. The articles that met the inclusion criteria provided evidence suggesting that preoperative assessment should be comprehensive, hemodynamic goals should be established, anesthesia providers should be familiar with the underlying pathology, and cross-consultations between surgeons and anesthesia providers are essential for achieving satisfactory outcomes. Furthermore, patient care should extend beyond the surgical procedure into postoperative recovery in the post-anesthesia care unit (PACU) or intensive care unit (ICU) setting. In conclusion, it is vital for anesthetic management strategies to accommodate the unique needs of PAH patients to optimize their safety during perioperative care.

Outcomes and Prognostic Factors of Pulmonary Hypertension Patients Undergoing Emergent Endotracheal Intubation

Background: Emergent endotracheal intubations (ETI) in pulmonary hypertension (PH) patients are associated with increased mortality. Post-intubation interventions that could increase survivability in this population have not been explored. We evaluate early clinical characteristics and complications following emergent endotracheal intubation and seek predictors of adverse outcomes during this post-intubation period. Methods: Retrospective cohort analysis of adult patients with groups 1 and 3 PH who underwent emergent intubation between 2005-2021 in medical and liver transplant ICUs at a tertiary medical center. PH patients were compared to non-PH patients, matched by Charlson Comorbidity Index. Primary outcomes were 24-h post-intubation and inpatient mortalities. Various 24-h post-intubation secondary outcomes were compared between PH and control cohorts. Results: We identified 48 PH and 110 non-PH patients. Pulmonary hypertension was not associated with increased 24-h mortality (OR 1.32, 95%CI 0.35-4.94, P = .18), but was associated with inpatient mortality (OR 4.03, 95%CI 1.29-12.5, P = .016) after intubation. Within 24 h post-intubation, PH patients experienced more frequent acute kidney injury (43.5% vs. 19.8%, P = .006) and required higher norepinephrine dosing equivalents (6.90 [0.13-10.6] mcg/kg/min, vs. 0.20 [0.10-2.03] mcg/kg/min, P = .037). Additionally, the median P/F ratio (PaO₂/FiO₂) was lower in PH patients (96.3 [58.9-201] vs. 233 [146-346] in non-PH, P = .001). Finally, a post-intubation increase in PaCO₂ was associated with mortality in the PH cohort (post-intubation change in PaCO₂ +5.14 ± 16.1 in non-survivors vs. -18.7 ± 28.0 in survivors, P = .007). Conclusions: Pulmonary hypertension was associated with worse outcomes after emergent endotracheal intubation than similar patients without PH. More importantly, our data suggest that the first 24 hours following intubation in the PH group represent a particularly vulnerable period that may determine long-term outcomes. Early post-intubation interventions may be key to improving survival in this population.

Tricuspid regurgitation pressure gradient to diagnose pulmonary hypertension: a diagnostic accuracy study

Background Pulmonary hypertension carries significant morbidity and mortality in children. Early diagnosis and management may improve outcomes in children with pulmonary hypertension. Heart catheterization, a gold standard for diagnosing pulmonary hypertension, is an invasive procedure and not widely available. Echocardiography can be used as an alternative diagnostic tool for pulmonary hypertension. Objective To determine the diagnostic value of tricuspid regurgitation pressure gradient on echocardiography compared to heart catheterization to diagnose pulmonary hypertension in children. Methods This diagnostic test study was done with medical record data of children with acyanotic congenital heart disease who underwent cardiac catheterization and echocardiography procedures from January 2018 to December 2020 at Dr. Sardjito Hospital, Yogyakarta, Indonesia. Data were analyzed to obtain sensitivity, specificity, positive and negative predictive values, as well as positive and negative likelihood ratios. Results A total of 98 children with acyanotic congenital heart disease were included. The sensitivity and specificity of the tricuspid regurgitation pressure gradient to determine pulmonary artery pressure compared to heart catheterization were 64.4% and 54.5%, respectively. The positive likelihood ratio was 1.42. The pre-test and post-test probability of this study were 88.7% and 91.7%, respectively. Conclusion Tricuspid regurgitation pressure gradient measured using echocardiography has poor sensitivity and specificity to diagnose pulmonary hypertension.

PATET ratio by Doppler echocardiography: noninvasive detection of pediatric pulmonary arterial hypertension

Pulmonary artery acceleration time (PAT) and PAT: ejection time (PATET) ratio are echocardiographic measurements of pulmonary arterial hypertension (PAH). These noninvasive quantitative measurements are ideal to follow longitudinally through the clinical course of PAH, especially as it relates to the need for and/or response to treatment. This review article focuses on the current literature of PATET measurement for infants and children as it relates to the shortening of the PATET ratio in PAH. At the same time, further development of PATET as an outcome measure for PAH in preclinical models, particularly mice, such that the field can move forward to human clinical studies that are both safe and effective. Here, we present what is known about PATET in infants and children and discuss what is known in preclinical models with particular emphasis on neonatal mouse models. In both animal models and human disease, PATET allows for longitudinal measurements in the same individual, leading to more precise determinations of disease/model progression and/or response to therapy. IMPACT: PATET ratio is a quantitative measurement by a noninvasive technique, Doppler echocardiography, providing clinicians a more precise/accurate, safe, and longitudinal assessment of pediatric PAH. We present a brief history/state of the art of PATET ratio to predict PAH in adults, children, infants, and fetuses, as well as in small animal models of PAH. In a preliminary study, PATET shortened by 18% during acute hypoxic exposure compared to pre-hypoxia. Studies are needed to establish PATET, especially in mouse models of disease, such as bronchopulmonary, as a routine measure of PAH.

Veno-Arterial Extracorporeal Membrane Oxygenation Rescue in a Patient With Pulmonary Hypertension Presenting for Revision Total Hip Arthroplasty: A Case Report and Narrative Review

Patients with pulmonary hypertension (PH) are at an increased risk of perioperative morbidity and mortality when undergoing non-cardiac surgery. We present a case of a 57-year-old patient with severe PH, who developed cardiac arrest as the result of right heart failure, undergoing a revision total hip arthroplasty under combined spinal epidural anesthesia. Emergent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was undertaken as rescue therapy during the pulmonary hypertensive crisis and a temporizing measure to provide circulatory support in an intensive care unit (ICU). We present a narrative review on perioperative management for patients with PH undergoing non-cardiac surgery. The review goes through the updated hemodynamic definition, clinical classification of PH, perioperative morbidity, and mortality associated with PH in non-cardiac surgery. Pre-operative assessment evaluates the type of surgery, the severity of PH, and comorbidities. General anesthesia (GA) is discussed in detail for patients with PH regarding the benefits of and unsubstantiated arguments against GA in non-cardiac surgery. The literature on risks and benefits of regional anesthesia (RA) in terms of neuraxial, deep plexus, and peripheral nerve block with or without sedation in patients with PH undergoing non-cardiac surgery is reviewed. The choice of anesthesia technique depends on the type of surgery, right ventricle (RV) function, pulmonary artery (PA) pressure, and comorbidities. Given the differences in pathophysiology and mechanical circulatory support (MCS) between the RV and left ventricle (LV), the indications, goals, and contraindications of VA-ECMO as a rescue in cardiopulmonary arrest and pulmonary hypertensive crisis in patients with PH are discussed. Given the significant morbidity and mortality associated with PH, multidisciplinary teams including anesthesiologists, surgeons, cardiologists, pulmonologists, and psychological and social worker support should provide perioperative management.

Periprocedural safety and outcome after pump implantation for intravenous treprostinil administration in patients with pulmonary arterial hypertension

Methods

In this retrospective observational study, we analyzed all patients with pulmonary arterial hypertension undergoing LenusPro® pump implantation between November 2013 and October 2019 at our center. Periprocedural safety was assessed by describing all complications that occurred within 28 days after surgery; complications that occurred later were described to assess long-term safety. Clinical outcomes were measured by comparison of clinical parameters and echocardiographic measurements of right ventricular function from baseline to 6-months-follow-up.

Results

Fifty-four patients underwent LenusPro® pump implantation for intravenous treprostinil treatment during the investigation period. Periprocedural complications occurred in 5 patients; the only anesthesia-related complication (right heart failure with recovery after prolonged intensive care and death in the further course) occurred in the only patient who underwent general anesthesia. All other patients underwent local anesthesia with or without short-acting (analgo-) sedation. Eighteen long-term complications occurred in 15 patients, most notably pump pocket or catheter related problems. Transplant-free survival rates at 1, 2, and 3 years were 77 %, 56 %, and 48 %, respectively.

Conclusions

Subcutaneous pump implantation under local anesthesia and conscious analgosedation while avoiding intubation and mechanical ventilation is feasible in patients with advanced PAH. Controlled studies are needed to determine the safest anesthetic approach for this procedure.

Background/Objectives

Intravenous treprostinil treatment via a fully implantable pump is a treatment option for patients with advanced pulmonary arterial hypertension. However, there is no consensus on the preferred anesthetic approach for the implantation procedure. Primary objective was to assess periprocedural safety with particular attention to feasibility of local anesthesia and conscious analgosedation instead of general anesthesia. Long-term safety and clinical outcomes were secondary endpoints.

Preoperative Assessment and Perioperative Management of the Patient with Pulmonary Vascular Disease

The incidence of pulmonary hypertension (PH) in patients undergoing noncardiac surgery has increased steadily over the past decade. Patients with known PH have significantly higher perioperative morbidity and mortality than those without PH. Moreover, a substantial number of patients may have occult disease. It, therefore, is of paramount importance for perioperative providers to recognize high-risk patients and treat them appropriately. This review first provides an overview of PH pathophysiology, then estimates the perioperative incidence of PH and its impact on surgical outcomes, and finally outlines a perioperative management strategy.

[Anesthesiological aspects of liver transplantation]

Liver transplantation (LTPL) is the only curative option for patients with end stage liver disease (ESLD) or with hepatocellular carcinoma (HCC). Eurotransplant in Leiden, the Netherlands, is responsible for organ allocation. The model of end stage liver disease (MELD) score, which describes the severity of the liver disease, is decisive for organ allocation. The heterogeneous patient collective and hepatic-related comorbidities and their dynamics represent challenges. The anesthesiologist is responsible for evaluating the overall prognosis, whereby cardiac, pulmonary, renal and neurological comorbidities must be taken into consideration. During LTPL surgery is divided into several stages. Besides volume management, heat preservation and coagulation management, major challenges for the anesthesiologist are hemodynamic stabilization and regulation of the acid-base balance.

Inhaled nitric oxide might be a contributing tool for successful resuscitation of cardiac arrest related to pulmonary hypertension

We describe a case where inhaled nitric oxide (iNO) was successfully initiated during cardiopulmonary resuscitation (CPR) in a younger patient with cardiac arrest related to pulmonary hypertension after disseminated intravascular coagulation (DIC) postpartum bleeding and hysterectomy. This case illustrates that iNO might be a potential lifesaving tool for resuscitation of patients with cardiac arrest related to pulmonary hypertension, for whom most other resuscitation strategies often are futile.

Feasibility of On-table Extubation After Cardiac Surgery with Cardiopulmonary Bypass: A Randomized Clinical Trial

BACKGROUND

The use of short-acting anesthetics, muscle relaxation, and anesthesia depth monitoring allows maintaining sufficient anesthesia depth, fast recovery, and extubation of the patients in the operating room (OR). We evaluated the feasibility of extubation in the OR in cardiac surgery.

METHODS

This clinical trial was performed on 100 adult patients who underwent elective noncomplex cardiac surgery using cardiopulmonary bypass. Additional to the routine monitoring, the patients' depth of anesthesia and neuromuscular blocked were assessed by bispectral index and nerve stimulator, respectively. In the on-table extubation (OTE) group (n = 50), a limited dose of sufentanil (0.15 µg/kg/h) and inhalational anesthetics were used for early waking. In the control group (n = 50), the same anesthesia-inducing drugs were used but the dose of sufentanil during the operation was 0.7 - 0.8 µg/kg/h. After the operation, cardiorespiratory parameters and ICU stay were documented.

RESULTS

Demographic and clinical variables were comparable in both study groups. In the OTE group, we failed to extubate two patients in the OR (success rate of 96%). There were no significant differences between the two groups in terms of systolic and diastolic blood pressure at the time of entering the ICU (P > 0.05). Heart rate was lower in the OTE than in the control group at ICU admission (89.4 ± 13.1 vs. 97.6 ± 12.0 bpm; P = 0.008). The ICU stay time was lower in the OTE group (34 (21.5 - 44) vs. 48 (44 - 60) h; P = 0.001).

CONCLUSIONS

Combined inhalational-intravenous anesthesia along with using multiple anesthesia monitoring systems allows reducing the dose of total anesthetics and maintaining adequate anesthesia depth during noncomplex cardiac surgery with cardiopulmonary bypass. Thus, extubation of the trachea in the OR is feasible in these patients.

Avaliação metabólica e hemodinâmica de dois protocolos de sedação prolongada em cães

RESUMO Objetivou-se determinar a viabilidade de dois protocolos de sedação para ventilação prolongada em cães e seus efeitos hemodinâmicos e metabólicos. Doze cães, alocados aleatoriamente em dois grupos (n=6), receberam infusão contínua de midazolam (0,5mg/kg/h), fentanil (10µg/kg/h) e propofol (18mg/kg/h) no GMF ou cetamina (0,6mg/kg/h), morfina (0,26mg/kg/h) e propofol (18mg/kg/h) no GCM, durante 24 horas. Os cães foram ventilados mecanicamente com FiO2 de 40%, mantendo-se a normocapnia. A FC diminuiu 32% no GMF e 34% no GCM ao longo do tempo, reduzindo o IC em 24% no GMF e em 29% no GCM. A CaO2, o CvmO2, a DO2 e o VO2 diminuíram no GCM (5%, 16%, 31% e 7%) e no GMF (4%, 19%, 26% e 15%), respectivamente. A TEO2 aumentou 32% no GMF e 36% no GCM, sem diferenças entre grupos, porém a calorimetria indireta demonstrou diminuição do VO2, minimizando a redução da DO2. Não houve diferença entre os tempos para extubação, deambulação e recuperação total, com médias globais (minutos) de 33,8±15,9, 134,8±60,7 e 208±77,5, respectivamente. Conclui-se que ambos os protocolos permitiram a ventilação mecânica, com redução do IC e da DO2, porém sem prejuízos hemodinâmicos e metabólicos, podendo ser utilizados com segurança em cães hígidos.

Imatinib relaxes the pulmonary venous bed of guinea pigs

Background

Recently, the IMPRES study revealed that systemic imatinib improves exercise capacity in patients with advanced pulmonary arterial hypertension. Imatinib blocks the tyrosine kinase activity of the platelet-derived growth factor (PDGF)-receptor (PDGFR), acts antiproliferative and relaxes pulmonary arteries. However so far, the relaxant effects of imatinib on pulmonary veins (PVs) and on the postcapillary resistance are unknown, although pulmonary hypertension (PH) due to left heart disease (LHD) is most common and primarily affects PVs. Next, it is unknown whether activation of PDGFR alters the pulmonary venous tone. Due to the reported adverse effects of systemic imatinib, we evaluated the effects of nebulized imatinib on the postcapillary resistance.

Methods

Precision-cut lung slices (PCLS) were prepared from guinea pigs. PVs were pre-constricted with Endothelin-1 (ET-1) and the imatinib-induced relaxation was studied by videomicroscopy; PDGF-BB-related vascular properties were evaluated as well. The effects of perfused/nebulized imatinib on the postcapillary resistance were studied in cavine isolated perfused lungs (IPL). Intracellular cAMP/cGMP was measured by ELISA in PVs.

Results

In PCLS, imatinib (100 μM) relaxed pre-constricted PVs (126%). In PVs, imatinib increased cAMP, but not cGMP and inhibition of adenyl cyclase or protein kinase A reduced the imatinib-induced relaxation. Further, inhibition of K_ATP-channels, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\mathrm{BK}}_{\mathrm{Ca}}^{2+} $$\end{document}BKCa2+-channels or K_v-channels diminished the imatinib-induced relaxation, whereas inhibition of NO-signaling was without effect. In the IPL, perfusion or nebulization of imatinib reduced the ET-1-induced increase of the postcapillary resistance. In PCLS, PDGF-BB contracted PVs, which was blocked by imatinib and by the PDGFR-β kinase inhibitor SU6668, whereas inhibition of PDGFR-α (ponatinib) had no significant effect. Conversely, PDGFR-β kinase inhibitors (SU6668/DMPQ) relaxed PVs pre-constricted with ET-1 comparable to imatinib, whereas the PDGFR-α kinase inhibitor ponatinib did not.

Conclusions

Imatinib-induced relaxation depends on cAMP and on the activation of K⁺-channels. Perfused or nebulized imatinib significantly reduces the postcapillary resistance in the pre-constricted (ET-1) pulmonary venous bed. Hence, nebulization of imatinib is feasible and might reduce systemic side effects. Conversely, PDGF-BB contracts PVs by activation of PDGFR-β suggesting that imatinib-induced relaxation depends on PDGFR-β-antagonism. Imatinib combines short-term relaxant and long-term antiproliferative effects. Thus, imatinib might be a promising therapy for PH due to LHD.

Evaluation of the influence of pulmonary hypertension in ultra-fast-track anesthesia technique in adult patients undergoing cardiac surgery

Objective

To evaluate the influence of pulmonary hypertension in the ultra-fast-track anesthesia technique in adult cardiac surgery.

Methods

A retrospective study. They were included 40 patients divided into two groups: GI (without pulmonary hypertension) and GII (with pulmonary hypertension). Based on data obtained by transthoracic echocardiography. We considered as the absence of pulmonary hypertension: a pulmonary artery systolic pressure (sPAP) <36 mmHg, with tricuspid regurgitation velocity <2.8 m/s and no additional echocardiographic signs of PH, and PH as presence: a sPAP >40 mmHg associated with additional echocardiographic signs of PH. It was established as influence of pulmonary hypertension: the impossibility of extubation in the operating room, the increase in the time interval for extubation and reintubation the first 24 hours postoperatively. Univariate and multivariate analyzes were performed when necessary. Considered significant a P value <0.05.

Results

The GI was composed of 21 patients and GII for 19. All patients (100%) were extubated in the operating room in a medium time interval of 17.58±8.06 min with a median of 18 min in GII and 17 min in GI. PH did not increase the time interval for extubation (P=0.397). It required reintubation of 2 patients in GII (5% of the total), without statistically significant as compared to GI (P=0.488).

Conclusion

In this study, pulmonary hypertension did not influence on ultra-fast-track anesthesia in adult cardiac surgery.

Management of pulmonary hypertension and right heart failure in the intensive care unit

Management of acute right ventricular failure, both with and without coexisting pulmonary hypertension, is a common challenge encountered in the intensive care setting. Both right ventricular dysfunction and pulmonary hypertension portend a poor prognosis, regardless of the underlying cause and are associated with significant morbidity and mortality. The right ventricle is embryologically distinct from the left ventricle and has unique morphologic and functional properties. Management of right ventricular failure and pulmonary hypertension in the intensive care setting requires tailored hemodynamic management, pharmacotherapy, and often mechanical circulatory support. Unfortunately, our understanding of the management of right ventricular failure lags behind that of the left ventricle. In this review, we will explore the underlying pathophysiology of the failing right ventricle and pulmonary vasculature in patients with and without pulmonary hypertension and discuss management strategies based on evidence-based studies as well as our current understanding of the underlying physiology.

Perioperative management of patients with severe pulmonary hypertension in major orthopedic surgery: experience-based recommendations

Introduction: It is known that pulmonary hypertension is associated with worse outcome in both cardiac and non-cardiac surgery. The aims of our retrospective analysis were to evaluate the outcomes of our patients with pulmonary hypertension undergoing major orthopedic surgery and to give experience-based recommendations for the perioperative management.

Material and methods: From 92 patients with pulmonary hypertension undergoing different kinds of surgical procedures from 2011–2014 in a tertiary academic hospital we evaluated 16 patients with major orthopedic surgery for perioperative morbidity and mortality.

Results: Regarding the in-hospital morbidity and mortality, one patient died postoperatively due to pulmonary infection and right heart failure (6.25%) and 6 patients suffered significant postoperative complications (37.5%; bleeding = 1, infection = 1, wound healing deficits = 3; dysrhythmia = 1).

Conclusion: Our data show that major orthopedic surgery is feasible with satisfactory outcome even in cases of severe pulmonary hypertension by an individualized, disease-adapted interdisciplinary treatment concept.