Transesophageal echocardiography images were acquired from a 30-year-old patient with group 1 pulmonary hypertension during bilateral orthotopic lung transplantation. The relative chamber sizes are shown pre (fig. 1) and post (fig. 2) transplantation. Preoperative pulmonary artery pressures were 142/54 with a systemic blood pressure of 128/64. The pulmonary artery pressures decreased to 18/8 with similar systemic pressure postoperatively. Together these images demonstrate the classic findings of severe pulmonary artery pressures with an enlarged right ventricle and displacement of the interventricular septum toward the left ventricle (Supplemental Digital Content, https://links.lww.com/ALN/D166).
Pulmonary hypertension is defined as a mean pulmonary artery pressure of more than 20 mmHg. Patients with pulmonary hypertension undergoing noncardiac surgery are at high risk for major adverse cardiovascular events, including death, acute myocardial infarction, and stroke. Right ventricular overload can alter left ventricular geometry and impair output flow, which may lead to reduced myocardial oxygen supply and subsequent right ventricular ischemia if left untreated. Intraoperative management of these patients focuses on decreasing pulmonary vascular resistance (PVR) with selective pulmonary vasodilators such as epoprostenol, nitric oxide, iloprost, and prostacyclin while promoting pulmonary vasodilation by avoiding hypoxemia, hypercapnia, and acidosis. Other considerations include maintaining preload and supporting right ventricular function with the use of inotropes if necessary. Decreasing PVR can also improve hemodynamic stability. As PVR is decreased and right ventricular function improves, the interventricular septum will approach midline, thereby minimizing its influence on left ventricular function.