The Pathophysiology and Management of Perioperative Pulmonary Hypertension with Specific Emphasis on the Period following Cardiac Surgery

Pulmonary hypertension, right ventricular dysfunction, and RV failure are common occurrences following CPB. The endothelium is now recognized as an important organ and is central to the pathophysiology and management of this condition. Current progress has arisen from the development of newer methods and the refinement of older methods attempting to protect the endothelium. Modern methods attempting to preserve endothelial function (thereby preventing pulmonary vasoconstriction and RV dysfunction) include new pharmacological inhibitors of the inflammatory response to CPB, improved myocardial protection using substrate enhanced cardioplegia, improved cardioplegia delivery techniques combined with monitoring by myocardial contrast TEE, and new minimally invasive surgical techniques not requiring extracorporeal support. Progress in therapeutic methods attempting to reverse pulmonary hypertension, RV dysfunction, and support of the failing right ventricle include the application of nitric oxide, prostacyclin, other pulmonary selective vasodilators, and improved ventricular assist devices that provide support to the right ventricle until recovery of the myocardium occurs or serve as a bridge to transplantation.