PURPOSE:The purpose of this study was to compare the incidence of perioperative (<30day) mortality and morbidity in adult patients with angiographically proven Pulmonary Hypertension (PH),undergoing Noncardiac Surgery (NCS) with that of controls.
METHODS:The study population included over 8000 patients who underwent Right Heart Catheterization (RHC) at a major tertiary care facility between 2002 and 2006. The data was cross-referenced with IMPACT (Internal Medicine Preoperative Assessment Consultation, Treatment) data that included all patients who underwent preoperative evaluation for NCS during the same period. Patients <18 years,those who underwent cardiac surgery, or procedures under local anesthesia/ sedation and patients with a pre-existing tracheostomy were excluded. Preoperative morbidity and postoperative outcome data were used from the surgical procedure closest to the date of RHC. Cases were defined as patients with mean pulmonary arterial pressure (MPAP) >25 mmHg, within 3 years of NCS. Controls with comparable demographics, morbidities and surgical procedures were selected from the RHC database, defined as MPAP <25 mmHg.
RESULTS:A total of 102 patients with PH, underwent NCS of which, 30 had a significant postoperative complication (OR:7.14), that included 2 deaths. Compared to controls Congestive Heart failure (CHF, p<0.0004;OR:9.50), Hemodynamic instability (p<0.006;OR:10.7), Sepsis (p<0.0002) and Respiratory failure (p<0.005) were amongst the major postoperative complications. Patients with PH were more likely to be admitted to ICU (p<0.007;OR:4.3), need longer ventilatory support (p<0.01) and more frequent readmission to the hospital within 30 days (p<0.053). In the PH group, LVEF% (p<0.013); Dilated Right atrium (p<0.02); Right Ventricular Systolic pressure (RVSP, p<0.028) on preoperative surface echocardiogram were associated with postoperative complications. Although RVSP by echo was associated with postoperative complications; 17 out of 71 cases had RVSP<35 mmHg, and 37 of 74 controls had RVSP >35mmHg. Amongst the hemodynamic measures, mean pulmonary capillary wedge pressure (PCWP, p<0.016) and mean pulmonary vascular resistance (PVR, p<0.002) obtained by RHC were associated with postoperative complications.
CONCLUSION:Patients with PH are at risk of major complications after NCS, determined by the severity of preoperative PCWP, PVR and RA dilation. Although preoperative RVSP can be a associated with postoperative complications it’s reliability is questionable.
CLINICAL IMPLICATIONS:Patients with known or suspected PH should be appropriately screened/ investigated before NCS.
DISCLOSURE:Roop Kaw, No Financial Disclosure Information; No Product/Research Disclosure Information