Noncardiac surgery for severe pulmonary hypertension: two surgeries in one patient and a review of the literature.

Introduction and importance: We present an analysis of the use of the multimodality approach for the treatment of patients with severe pulmonary arterial hypertension (PAH) who underwent surgery due to recurrent jaundice in the course of biliary obstruction and three years after surgery for breast cancer.

Case presentation: A 66-year-old woman with a 5-year documented history of associated PAH related to scleroderomia. Because of cholangitis, she underwent endoscopic stenting of the common bile duct. At the time of the operation, she underwent three rounds of endoscopic removal of the prosthesis from the choledochal duct and restenting procedures due to recurrent jaundice during biliary obstruction. She underwent surgery via epidural thoracic anesthesia with intravenous sedation. Three years later, the patient was diagnosed with breast cancer. She underwent surgery via regional neuraxial blocks with intravenous sedation, and mastectomy with axillary lymphadenectomy was performed.

Clinical discussion: According to the Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension, a general recommendation before surgery cannot be made. The perioperative optimization of pulmonary hypertension (PH) therapy should include assessments of functional status, severity of disease and comorbidities. The optimal specific treatment of PH by a cardiologist before the planned surgery of a patient and the selection of the optimal surgery time were crucial. The second very important element was the selection of the type of anesthesia.

Conclusion: Our patient underwent high-risk surgery because, first, a large abdominal procedure was performed, and second, the operation was performed without the possibility of special preoperative modification therapy. The third, PH severity was very advanced, with higher pulmonary artery pressure than systemic blood pressure. Patients with advanced PH could experience a relatively smooth intra-operative course in non-cardiac surgery when managed with current operative and anesthetic strategies, as in the case described.