Pulmonary hypertension and right ventricular failure
Stem
A 61-year-old woman, 68 kg, with idiopathic pulmonary arterial hypertension needs a hemiarthroplasty for a displaced femoral neck fracture. She takes macitentan and tadalafil and receives continuous IV epoprostenol through a tunneled line. Her last right heart catheterization showed a mean PA pressure of 46 mmHg, wedge 10 mmHg and PVR 7 Wood units. Echo shows a dilated right ventricle with mildly reduced function. She is in sinus rhythm, BP 112/70, SpO2 94% on room air.
Question
How will you anesthetize her, and what are you trying to protect?
Ideal answer
HeadlineI protect a right ventricle against high afterload: nothing that raises PVR, systemic pressure kept up so the right coronary stays perfused.1
- Epoprostenol uninterrupted on its own dedicated line, never flushed or used for drugs, because pulmonary vasodilator therapy continues perioperatively.1
- Arterial line before induction, vasopressor infusion running, because brief hypotension starts right ventricular ischemia; inhaled nitric oxide and an inotrope ready.
- Fascia iliaca block first, so positioning causes no pain or PVR surge; then a slow opioid-based general under vasopressor cover, or a slowly titrated epidural; no single-shot spinal, because the abrupt SVR drop is poorly tolerated.1
- Ventilate gently: no hypoxia, hypercarbia, acidosis or hypothermia; low peak and plateau pressures; higher FiO2 over high PEEP.1
- Uncemented prosthesis if possible, because cement embolization raises pulmonary resistance; hypotension treated early, vasopressin or norepinephrine, then ICU, in a center with a pulmonary hypertension team.
Breaking down the answer
- Define the disease — pulmonary hypertension is a mean PA pressure above 20 mmHg at rest; pulmonary arterial hypertension adds PVR above 2 Wood units with a wedge of 15 mmHg or less.2 Hers is precapillary, where the RV is most at risk.
- The spiral — hypotension lowers right coronary perfusion, the ventricle dilates and shifts the septum, the left ventricle underfills, and pressure falls further. Every step breaks a link.
- Pressor choice — she tolerates hypotension poorly; vasopressin or phenylephrine restores SVR, and norepinephrine adds right ventricular inotropy.1
- Cement is a specific threat — embolized marrow and cement raise PVR when this ventricle can least afford it; asking about an uncemented stem shows judgment.
Follow-up question
Seconds after the femoral component is cemented, her SpO2 falls to 84%, end-tidal CO2 drops from 36 to 21 mmHg, and her pressure is 68/40. TEE shows a severely dilated right ventricle with a D-shaped left ventricle.
What do you do?
Follow-up answer
HeadlineAcute RV failure from cement and marrow embolism on fixed pulmonary hypertension. I stop the surgeon, call for help, and warn ECMO may follow.
I give 100% oxygen and raise ventilation to clear CO2 without high airway pressures, and restore systemic pressure first with vasopressin and norepinephrine, because the right coronary needs it. Then an inotrope such as epinephrine and inhaled nitric oxide; no more fluid, because the ventricle is already distended.1 I correct acidosis. If she arrests, CPR and ECMO as a bridge to recovery.1 I reassess septal position and RV size on TEE; she goes to the ICU intubated.
Pitfalls that cost points
- Hyperinflating with high PEEP to fix hypoxemia, which raises PVR.
- Giving a pulmonary vasodilator before restoring systemic pressure.
Rapid-fire
Q: Which physiologic triggers do you avoid? A: Hypoxia, hypercarbia, acidosis and hypothermia, plus high peak and plateau airway pressures.1
Q: Is ketamine safe? A: Its effect on PVR is generally minimal and offset by sympathetic stimulation, so careful use is acceptable.1
Q: Why avoid one-lung ventilation where possible? A: Hypoxic pulmonary vasoconstriction in the collapsed lung adds afterload to a failing right ventricle.1
Q: What is the definitive treatment for chronic thromboembolic pulmonary hypertension? A: Pulmonary endarterectomy, with lifelong anticoagulation.2
Numbers to know
| Item | Value |
|---|---|
| PH definition | mPAP >20 mmHg at rest2 |
| PAH: PVR | >2 Wood units2 |
| PAH: wedge | ≤15 mmHg2 |
| Her PVR | 7 Wood units (precapillary) |
Links
- Heart failure and reduced ejection fraction, Vasopressors and inotropes: choosing and titrating, Choosing an induction agent, Bone cement, tourniquets and hip fracture, Cardiopulmonary bypass: conduct and separation
- Atlas: The 11 TEE views; Ventricular function and wall motion
- 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension
Sources
- 1.Anesthesia for Patients With Pulmonary Hypertension or Right Heart Failure · StatPearls, 2025 · statpearls.com
- 2.2022 ESC/ERS Guidelines for Pulmonary Hypertension: Key Points · ACC, 2022 · acc.orgACC summary of the 2022 ESC/ERS guideline (hemodynamic definitions).
Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.