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Abstract
Pulmonary hypertension is an increase in blood pressure in the pulmonary artery or lung vasculature. Depending on the cause, it can be a severe disease with a markedly decreased exercise tolerance and right-sided heart failure.
One of the most common causes of pulmonary hypertension is congenital heart disease.
The most pronounced problem dealt with in patients with pulmonary hypertension is the impairment in right ventricular function up to right-sided heart failure. The primary cause of right-ventricular failure should be corrected whenever possible. The right ventricular aflerload should be reduced by decreasing the pulmonary artery pressure (e.g. by administering pulmonary vasodilators such as inhaled NO or prostacyclin) and limiting plateau pressure in mechanically ventilated patients. Positive inotropic agents improve cardiac output and coronary perfusion (e.g. beta-agonists and phosphodiesterase inhibitors).
Calciumsensitizers, specifically Levosimendan, enhance contractility withoutincreasing myocardial oxygen consumption.
Pulmonary hypertension markedly increase morbidityand mortality in patients undergoing surgery that is why proper individual management and optimization of therapy may markedly reduce the incidence of complications.
The conceptual shift in the pathogenesis of pulmonary hypertension from vasoconstrictive to a vasoproliferative process has been paralleled by a shift in the approach to treatment.
Treatment of pulmonary hypertension in congenital heart disease is directed to correct the congenital anomly before irreversible changes occure in the pulmonary vasculature.
Sometimes, decreasing in pulmonary artery pressure is needed early by surgical intervention like pulmonary banding, atrial eptostomy and finally, lung or heart-lung transplantation in terminal cases.
The anesthetic management involves setting the proper plan for each individual patient and the nature of surgery.
Since general hyperthensive patients associated with congenital heart diseases, since general anesthesia has significant risks, limited regional anesthesia should be considered when appropriate.
General anesthesia remains the method of choice for major surgery, the perioperative risk could be minimized by identifying the effect of various anesthetic agents on pulmonary circulation, cardiac performance and systemic circulation.