It is difficult to provide overall recommendations for elective surgery since this encompasses a large spectrum of procedures. Nearly all PH specialists feel that exercise capacity, type of surgery, type of anesthesia, and what therapy a patient is receiving (for example, whether or not a patient is receiving epoprostenol), need to be considered in the decision to proceed with elective surgery. While broad guidelines are provided below, each surgical procedure should be evaluated on a case-by-case basis in conjunction with a PH specialist.
PAH patients with less severe functional impairment are more likely to tolerate the stress of elective surgery, and the risks of surgery in such patients is felt to be acceptable by most PAH specialists. However, a number of experts feel that all but the most necessary elective surgery (relief of severe pain, treatment of conditions likely to worsen and require emergency surgery, etc.) should be avoided in any patient with PAH, regardless of degree of functional impairment. In PAH patients with right heart failure, it is recommended that any surgery, other than that needed to treat a life-threatening problem, be avoided. Regardless of how good a patient's exercise capacity is, there is always a risk of complications with surgery, and it is strongly recommend that surgery, which is not medically necessary (such as plastic surgery purely to improve appearance), be avoided.
The risks of local anesthesia (numbing medicine under the skin) are low and this type of anesthesia is recommended when feasible. Any other type of anesthesia (spinal, epidural, and general) carries a greater risk for complications. Lengthy surgeries and procedures involving the chest or abdomen are also felt by the majority of PH specialists to have a higher risk for complications. It is recommended that PAH patients with any exercise impairment consider having procedures in which local anesthesia is not an option, performed at a center with expertise in the management of PH. Close interaction between patient, surgeon, anesthesiologist, and PH specialist is also recommended and are likely to allow for safe surgery when necessary.
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