Perioperative management of patients with Pulmonary Hypertension undergoing Non-Cardiac Surgery: A Systemic Review and UK Consensus Statement

Background: The risk of complications, including death, is markedly increased in patients with pulmonary hypertension (PH) undergoing anaesthesia for surgical procedures. We performed a systematic literature review of available studies in patients with PAH or chronic thromboembolic PH (CTEPH) undergoing non-cardiac, non-obstetric surgery, finding a mortality ranging between 2-18% in elective and 15-50% in emergency surgery. Methods/Results: We devised relevant clinical questions based on expert consensus opinion in order to provide recommendations of best practice, using a Delphi scoring method. Based on findings from our literature review and expert opinion, we provide 10 recommendations for best clinical practice involving (1) preoperative planning and the use of a perioperative MDT, (2) management of procedural sedation, (3) decision making where surgery is performed, (4) patient-related risk assessment, (5) procedure-related risk assessment, (6) perioperative optimization of PH therapies, (7) perioperative parenteral PAH therapy, (8) perioperative monitoring and anaesthetic management, (9) postoperative management, and (1) management of perioperative pulmonary hypertensive crises, including consideration of ECMO and lung transplantation. Areas for future research are also suggested. Conclusion: This was a collaborative project by UK PH services. We provide 10 recommendations for good clinical practice in this common clinical scenario, where risk assessment is crucial, as mortality remains high.