The Post-Anesthetic Care of Pediatric Patients With Pulmonary Hypertension

Correlation of Transthoracic Echocardiographic Estimates of Right Ventricular Pressure with Right Ventricular Pressure Measurements on Cardiac Catheterization in Children with Pulmonary Hypertension

OBJECTIVES

Evaluate the correlation of non-invasive echocardiographic estimates of right ventricular systolic pressure with measurements on cardiac catheterization in children with pulmonary hypertension.

DESIGN

Retrospective chart review.

SETTING

Quaternary academic children's hospital.

PARTICIPANTS

Patients younger than 18 years with a diagnosis of pulmonary hypertension and confirmatory cardiac catheterization from 2015 to 2018.

MEASUREMENTS AND MAIN RESULTS

We analyzed the correlation between measures of right ventricular systolic pressure using nonparametric Spearman rho (ρ) with statistical significance set at p < 0.05.

RESULTS

Children (N = 111) with biventricular circulation, strictly defined pulmonary hypertension, and adequate tricuspid regurgitation on echocardiogram to estimate right ventricular systolic pressure using the modified Bernoulli equation. Median age and weight were 4.3 years and 14.4 kg. Median right ventricular systolic pressure estimated by tricuspid regurgitant velocity on echocardiography was 55 mmHg (IQR 45-75 mmHg) plus right atrial pressure. On cardiac catheterization, median right ventricular systolic pressure was 57 mmHg (IQR 46-75 mmHg). Echocardiographic estimates of right ventricular systolic pressure were moderately well correlated with right ventricular systolic pressure directly measured on catheterization (ρ = 0.44, 95% CI 0.27-0.6, p < 0.001) with a median difference of 4 mmHg (IQR -10 to 17). Subgroup analysis revealed that echocardiography and catheterization measurements correlated well in children with suprasystemic right ventricular pressure on cardiac catheterization (ρ = 0.75, 95% CI 0.51-0.99, p < 0.001) although catheterization measurements were a median of 26 mmHg (IQR 12-31) higher than echocardiographic estimates in this subgroup.

CONCLUSIONS

In children with pulmonary hypertension, echocardiographic estimates of right ventricular pressure correlated moderately well with gold standard measurements by cardiac catheterization with stronger correlation in children with suprasystemic right ventricular pressures. This is reassuring for clinicians who must rely on echocardiography for risk stratification before anesthetizing children with pulmonary hypertension.

Who are at high risk of mortality and morbidity among children with congenital heart disease undergoing noncardiac surgery?

With advances in the development of surgical and medical treatments for congenital heart disease (CHD), the population of children and adults with CHD is growing. This population requires multiple surgical and diagnostic imaging procedures. Therefore, general anesthesia is inevitable. In many studies, it has been reported that children with CHD have increased anesthesia risks when undergoing noncardiac surgeries compared to children without CHD. The highest risk group included patients with functional single ventricle, suprasystemic pulmonary hypertension, left ventricular outflow obstruction, and cardiomyopathy. In this review, we provide an overview of perioperative risks in children with CHD undergoing noncardiac surgeries and anesthetic considerations in patients classified as having the highest risk.

Current understanding and perioperative management of pediatric pulmonary hypertension

Pediatric pulmonary hypertension is a complex disease with multiple, diverse etiologies affecting the premature neonate to the young adult. Pediatric pulmonary arterial hypertension, whether idiopathic or associated with congenital heart disease, is the most commonly discussed form of pediatric pulmonary hypertension, as it is progressive and lethal. However, neonatal forms of pulmonary hypertension are vastly more frequent, and while most cases are transient, the risk of morbidity and mortality in this group deserves recognition. Pulmonary hypertension due to left heart disease is another subset increasingly recognized as an important cause of pediatric pulmonary hypertension. One aspect of pediatric pulmonary hypertension is very clear: anesthetizing the child with pulmonary hypertension is associated with a significantly heightened risk of morbidity and mortality. It is therefore imperative that anesthesiologists who care for children with pulmonary hypertension have a firm understanding of the pathophysiology of the various forms of pediatric pulmonary hypertension, the impact of anesthesia and sedation in the setting of pulmonary hypertension, and anesthesiologists' role as perioperative experts from preoperative planning to postoperative disposition. This review summarizes the current understanding of pediatric pulmonary hypertension physiology, preoperative risk stratification, anesthetic risk, and intraoperative considerations relevant to the underlying pathophysiology of various forms of pediatric pulmonary hypertension.

Adenotonsillectomy for the Management of Pulmonary Hypertension in a Patient With Complex Congenital Heart Disease: A Case Report

Pulmonary hypertension is a feared complication in congenital heart disease patients. Patients with pulmonary hypertension are at risk for major perioperative cardiopulmonary complications when undergoing any surgical procedure, especially airway and laparoscopic procedures. We present the anesthetic management for a 2-year old with Down syndrome and complex cyanotic congenital heart disease undergoing tonsillectomy and adenoidectomy for severe obstructive sleep apnea.

Noteworthy Literature in 2015

This article is a review of the literature published during the 12 months of 2015, which is of interest to the congenital cardiac anesthesiologist. While the review is not exhaustive, it identifies 7 themes in the literature for 2015 and cites 78 peer-reviewed publications.