Is severe pulmonary hypertension always a contraindication to surgery?

Abstract

We report the case of a 69-year-old man pronounced ineligible for surgery by many cardiologists and cardiac surgeons on grounds of inadequately high risk because of his serious cardiac disease combined with severe pulmonary hypertension. Despite his serious condition, the patient had successful surgery after some additional examinations and at his own request. The patient had three-vessel coronary disease, severe degenerative aortic stenosis, severe diffuse left ventricular hypokinesia (EF = 25%) as well as a degenerative mitral valve defect with predominant regurgitation (3-4/5). After several examinations, the pulmonary hypertension was classified as severe mixed pulmonary hypertension with a major precapillary component (systolic pulmonary artery pressure about 80 mmHg, pulmonary capillary wedge pressure [PCW] 35 mmHg). Surgery was realized after successful right-heart catheterization with nitrogen oxide (NO) administration, resulting in decreases in the transpulmonary gradient (TPG) and pulmonary arterial resistance (PAR). The procedure was performed on cardiopulmonary bypass with blood cardioplegia. The patient had his aortic and mitral valves replaced with bioprostheses followed by triple coronary artery bypass surgery. Postoperative care of the patient required increased inotropic support combined with NO inhalation. The patient spent four days at the resuscitation unit to be discharged from hospital on postop day 15 and transferred to receive early postop rehabilitation at Poděbrady Spa.