Severe pulmonary hypertension and right ventricular failure complicate a total abdominal hysterectomy

The 2007 American College of Cardiology/American Heart Association guidelines report that no significant studies have been conducted assessing the perioperative risk of pulmonary hypertension in noncardiac surgery. However, the presence of right ventricular failure has been well documented to have poor prognostic implications. The presence of pulmonary hypertension and right ventricular failure present unique perioperative challenges. These include maintenance of adequate cardiac function, acid-base management, intraoperative monitoring, and postoperative pain management.

The authors report the case of a patient with severe pulmonary hypertension who underwent an open total abdominal hysterectomy. The case was complicated by known right ventricular failure, severe portal hypertension, obstructive sleep apnea, extensive smoking history, and systemic anticoagulation therapy. The patient was not a candidate for postoperative neuraxial analgesia because of the timing and dose of systemic anticoagulation. Two-dimensional transesophageal echocardiography was used for real-time visualization and intraoperative cardiac monitoring. The patient was transferred to the intensive care unit for careful titration of opioids and slow ventilator wean to extubation. The postoperative course proceeded without significant morbidity or mortality.

(a) Preoperative assessment of pulmonary hypertension, (b) postoperative pain control, (c) cardiovascular stability, and (d) intraoperative monitoring.

This case illustrates the unique challenges associated with pulmonary hypertension and right ventricular failure in the setting of noncardiac surgery. This case also demonstrates that continuous, real-time data provided by transesophageal echocardiography can be used to successfully manage a complicated patient with pulmonary hypertension.