Title

When Surgery Must Wait: The Crucial Role of Preoperative Optimization in Patients with Advanced Right Ventricular Failure and Pulmonary Hypertension

Introduction

Pulmonary arterial hypertension (PAH) with right

ventricular failure (RVF) poses major perioperative

challenges due to the compromised right ventricle's

difficulty with rapid hemodynamic changes. In

advanced cases, volume shifts, vasodilation, positive

pressure ventilation, and altered sympathetic tone can

lead to critical declines in cardiac output and coronary

perfusion. Effective management necessitates an

interdisciplinary approach focused on thorough

preoperative optimization to stabilize hemodynamics

and reduce risks.

 

Case Report

We present a 67-year-old female with history significant

for idiopathic PAH with fulminant RVF, chronic

respiratory failure on homeoxygen, chronic kidney

disease stage III, and HFpEF who was evaluated for

skin graft placement for non-healing, bilateral lower

extremity skin lesions following a low velocity

traumatic injury.

A pre-operative right heart catheterization was

performed and significant for worsening PAH

(73/26mmHg), RVF, and cardiogenic shock (CI = 1.4)

despite active management with remodulin, tadalafil,

and ambrisentan. Other pertinent medications included

furosemide, metolazone and milrinone for heart failure.

These findings were consistent with an ECHO

performed 10-months prior, which also demonstrated

normal LV function, severely reduced RVEF, severe RV

enlargement w/ septal deviation (D-sign), and severe

tricuspid regurgitation with IVC flow reversal (peak TR

gradient = 64mmHg).

 

Figure 1

 

Pathophysiology of RV Failure in Patients with PAH during the Preoperative Period. This diagram illustrates how

 

acute hemodynamic stressors lead to elevated pulmonary vascular resistance (PVR) and RV pressure, promoting RV dilation and

 

ischemia. The resulting RV failure diminishes RV stroke volume, causing a cascade of effects on left ventricular filling, cardiac

 

output, and systemic perfusion - ultimately exacerbating hypotension and RV perfusion deficits[1]

Figure 2

Proposed Mechanism of Action of Sotatercept. In PAH, reduced BMPR-II signaling leads to decreased BMP activity,

resulting in increased pro-proliferative signals and vascular remodeling via unregulated activin and growth differentiation

factor (GDF) pathways. Sotatercept - a ligand trap composed of a fusion between the Fc portion of IgG and the extracellular

domain of the human activin receptor type IIA - selectively binds to activins and GDFs, reducing their pro-proliferative effects

and rebalancing growth signals towards the antiproliferative BMP pathway . Overall, the downstream effects helps to restore

endothelial function and vascular integrity in PAH patients.[4]

 

Discussion and Plans for Management

The greatest risk for surgical patients with RVF secondary to PAH is the inability

of a pathologic RV to accommodate rapid changes in hemodynamics. Volume

shifts, vasodilation from anesthetic agents, positive pressure mechanical

ventilation, and altered sympathetic tone can all precipitate a cascade of

downstream effects that decrease cardiac output and coronary perfusion, which

ultimately increases risk for severe morbidity or mortality[2]

.

Ultimately, a multidisciplinary risk-based discussion between cardiac

anesthesiology, cardiology, pulmonology, and plastic surgery determined the

patient was not optimized and at a prohibitively high-risk for experiencing

adverse cardiovascular events during surgery. The patient’s most recent right heart

catheterization revealed severely elevated pulmonary artery pressures and

markedly low cardiac index despite aggressive management, suggesting further

increases in RV afterload could precipitate spiraling hemodynamic decline[3]. With

continued plans for wound care, antibiotics, and frequent close monitoring, the

team concluded that the risks of cardiovascular collapse during the perioperative

period overshadow concerns for wound infection. Therefore, the decision to delay

surgery and start Sotatercept – an activin signaling inhibitor approved by the FDA

in March 2024 – for better preoperative optimization was warranted considering

all conventional treatment of PAH has proved unsuccessful thus far[4]. In the end,

patient was continued on frequent wound assessments and an expedited initiation

of Sotatercept, with a reconsideration for intervention in 4-6 weeks pending

responsiveness to new medication.

This case illustrates the imperative for anesthesiologists to recognize the delicate

balance between surgical necessity and hemodynamic stability in patients with

severe PAH and RVF. The strategic postponement of surgery to optimize PAH

management serves as a critical learning point in prioritizing patient safety over

procedural urgency.

 

References

 

[1] Baumgartner N, De Jesus Perez V. Anesthesia for noncardiac surgery in patients with pulmonary hypertension or right heart failure. UpToDate.

 

[2] McGlothlin, Dana P et al. “ISHLT consensus statement: Perioperative management of patients with pulmonary hypertension and right heart failure undergoing

 

surgery.” The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation vol. 41,9 (2022): 1135-1194.

 

doi:10.1016/j.healun.2022.06.013

 

[3] Caddigan S, Granlund B. Anesthesia for Patients With Pulmonary Hypertension or Right Heart Failure. [Updated 2023 Jan 29]. In: StatPearls [Internet]. Treasure Island

 

(FL): StatPearls Publishing; 2024 Jan-

 

. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572071/

 

[4] Humbert, Marc et al. “Sotatercept for the Treatment of Pulmonary Arterial Hypertension.” The New England journal of medicine vol. 384,13 (2021): 1204-1215.

 

doi:10.1056/NEJMoa2024277