So, it's 8.30 and we can get started. I'd like to applaud you all for resisting the temptation to go to the beach, although I will note it's overcast, so I think you made the right decision. As you can tell, it's going to be casual, it's going to be fun, hopefully we'll learn something. There's a QR code here which you'll need to do some of the question and answer, so if you want to just go do the phone thing for the audience response, I'll give you a minute for that. That should show up throughout the talks anyways. Good, good. So, welcome to Preoperative Pulmonary Hypertension Shark Tank. I would just like to point out, I spent a lot of time on that logo, so I'm very proud of it. Also avoiding copyright. I'm Arun Jos. I'm from the University of Cincinnati. I'm also the Director of Pulmonary Hypertension at the Cincinnati VA. You can see my disclosures here, they don't really pertain to this talk. So, for this session, hopefully we can review some risk management and optimization strategies when optimizing pulmonary hypertension patients preoperatively and identify the associated knowledge gaps. So, I'm going to start by sort of going over what the session is going to look like, because it may be a little bit different. So, first we're going to have a case presentation and then you, the audience, is going to be the ones in charge of determining whether or not the offer flies. So, we're going to introduce the offers to you, the audience. Then we're going to review the pertinent facts of the case and then you, the audience, is going to select an offer. And then me, the presenter, is going to tell you what I think we should do and hopefully the majority of the audience agrees with me and we have a deal. And if not, I assume that would lead to questions and answers. So, that's kind of what it looks like, but doing is probably the best way of learning. So, we'll try a little practice case here. So, for example, the case might be, quote unquote case, you're a pulmonologist and you're attending chess in Hawaii and your potential offers to select from, well, maybe you're going to enhance your clinical and scientific knowledge. Maybe you want to hit up the beach, it's fair. Perhaps you want to go surfing or maybe you want to work on your tan. It has really great weather. So, then those are the offers and you keep those in the back of your head and then we run through the pertinence of the case. So, for example, in this particular case, you may not know that Hawaii has the second highest number of shark attacks in the United States. I didn't until I looked that up. However, also, you are much more likely to be killed by a cow, a snake, or even a vending machine as compared to a shark. So, you got to kind of balance that risk with benefit. And yes, there is a lot of clinical and science that occurs at chess, but days start pretty early. That's actually probably 5.15, but I'll be honest, I don't go to the 5.15 sessions. And Hawaii has excellent weather year-round, but if you show up with a tan in October, some people might be a little bit jealous. So, then we go back to our options and, you know, now reviewing the facts of the case, you can select from one of several options. So, then I would have you do so. You can go ahead and choose what your favorite option is. I think I have to do it. Oops, sorry, that was my bad. Try that again. Oh, I see the votes cast. Fascinating. All right, fantastic. And so, let's see what the breakdown is over here. Interesting. Okay, that's fair. I appreciate your honesty, guys. So, then, you know, at least thankfully the, you know, most selected was to enhance clinical and scientific knowledge. So, then I will detail my approach as the presenter. You know, we review the facts of the case. I happen to be deathly afraid of sharks. I also like to educate myself. And I don't, I'm not really big on tanning, to be honest. So, then I would seek the offer of to enhance my clinical and scientific knowledge. And then, yes, we do have a deal. So, success. And then that will lead into the question and answer portion. So, that's kind of how it works. But, obviously, with the clinical cases, it will be a little bit different. But, yeah. So, with that, I will escape out of here and invite Dr. Rivera-Lebron to give the first case, cholecystectomy and pulmonary hypertension. Well, thanks for putting this together. I thought it was very unique. The topic itself, I thought it was fascinating. It's actually my first time talking about this. So, it's a fresh new slide deck. My name is Belinda Rivera-Lebron. I work at the University of Pittsburgh, specialize in pulmonary hypertension. Here are my disclosures, none of which are relevant to this talk. So, scan the code, I guess, so that you can get with us interactive. We'll give you a second to do that. It's the same as the first code. Yeah. So, once you scan the first time, then you can just keep going with her. So, here's her case. 46-year-old female, has a mean pulmonary arterial pressure of 38, a wedge of 10, a cardiac output and thermoblyte of 5.2, index of 2.3, and a PVR of 5.4. She's been classified as idiopathic pulmonary arterial hypertension. She has normal renal function. She has WHO functional class 3, and her six-minute walk is around 200 meters, with her BMP being around 300. Normal pulmonary function test, she had a revealed 2.0 risk score of 10, and we'll go through that in more detail. Recently started on oral dual therapy with a PDE5 and an ERA. Hospitalized last month for acute cholecystitis. This is her second time around with cholecystitis this year alone, and surgery wants to do a cholecystectomy in six weeks, and they're asking about clearance. Sounds familiar? So, again, just put this on, kind of break down on the highlights of the case. So, again, 40-some-year-old female, newly diagnosed idiopathic PAH, had a BMP of 300, WHO functional class 3, around 200 meters. You see the hemodynamics. Here is just kind of like a breakdown of the highlights. So, here are our offers. So, our option number one is repeat a right heart cath with improved hemodynamics needed before surgery clearance. Second option is lower risk for is needed before surgery clearance. Third option is, okay, you're clear for a laparoscopic cholecystectomy in six weeks, okay? And the fourth option is, okay, you're cleared, but for an open cholecystectomy in six weeks, all right? So, think about it, and let's go through literature and see how that helps us decide what's the best option for this patient. So, a study of 17 million patients that were hospitalized for non-cardiac surgeries in the U.S. between 2004 and 2014 is shown here. It included, again, 17 million patients. And out of those, you can see here how over time, there is an increase in patients that have pulmonary hypertension that go through surgery. So, this is a really relevant talk for us. Now, as you know, because these are big database studies, they're all pulmonary hypertension identified by ICD-9 code. So, you know, take it with a grain of salt. Maybe not all of them have true pulmonary hypertension. But in this same study of that 17 million people that I was telling you about, you can see here how having pulmonary hypertension versus not having pulmonary hypertension definitely increases your major adverse outcomes, which include death, acute myocardial infarction, or stroke. So, 8% versus 2% in the patients who don't have pulmonary hypertension. And even after adjusting for some of the demographics, clinical comorbidities, whether it's urgent or emergent hospitalization, as you can see here, there's still a 43% risk of adverse outcome in this population. So, what are the actual perioperative complications in pulmonary hypertension? So, this was a retrospective study that included 145 patients, of which 55% were who group one pulmonary arterial hypertension, and only 14% of them were on basal dilators. So, that's a questionable, you know, red flag for me from this study. However, I'm just presenting this data. The other thing is that all these patients did not work characterized with right heart calf before their study. So, as you can see, half of the patients, roughly, were diagnosed with pulmonary hypertension based on echo parameters. 100% of them had general anesthesia, and in this study, there was a 7% mortality with a 42% risk of complication. And these were the complications that they underwent. So, respiratory failure, arrhythmias, congestive heart failure, renal insufficiency, and sepsis. So, you know, really important outcomes that we need to consider. So, how are these compared to patients in specifically pulmonary arterial hypertension? So, this study of 114 patients, all PAH patients, 100% of which we were on basal dilators, and all of them were diagnosed by right heart calf. As you can see here, their mean pulmonary pressure prior to surgery was 45. Roughly 80% of them had general anesthesia, and the other 20% had spinal anesthesia. And in here, the mortality is much lower, okay? So, it's a, you think that they would be a much sicker population because they had pulmonary arterial hypertension. However, if you guarantee that all of them are adequately treated, the outcomes are better. So, 3% mortality, only 6% complication rate. And when you look at it closely, you could see things like a six-minute walk of less than 400 meters was seen as a sign of poor outcome. The same as mean RA, so notice RA pressure, not pulmonary arterial pressure. And the use of vasopressors were all sort of increasing risk of poor outcomes, as well as having a surgery being emergently as opposed to an elective procedure. Notice here how surgery being performed at a pulmonary hypertension center was a protective or a benefit to the patient. And one thing that I found very interesting was that general versus spinal anesthesia was sort of not significantly sort of seen as a protective or as we sometimes often think about. So, kind of like interesting. So, I think that to be able to preoperatively combine the risk assessment for patients, we have to assess not only just the pulmonary hypertension risk factors, but we also have to think about surgery-related factors and patient-related factors. And we're going to go through that right now. So, for pulmonary hypertension, we have the well-defined risk scores that you know about. And I plugged here the ones that we were given for this particular patient. So, based on the Reveal 2.0 Risk Calculator, this patient is a high risk. You can see over nine. And based on the European guidelines, this one was an intermediate risk. However, I give you that the only thing is that we were not given all the parameters for this particular case. So, this patient may be a high risk based on this. I'm not saying that they're necessarily different. It's just that we were missing a few of the characteristics to be able to further classify this patient. So, optimally, these are the things that you're looking for. These are the things we're hoping for. We want particularly our RA pressure of 5 to 10. We want a mean pulmonary pressure of less than 35. And I would think that a cardiac index of over 2.2 are ideal for patients that are undergoing an elective surgery. But what about patient-related factors? So, comorbidities, and these are not limited, but they are very important. Coronary disease, LV dysfunction, arrhythmias, presence of renal dysfunction, liver dysfunction, other cardiopulmonary conditions like COPD, interstitial lung disease, and sleep apnea need to play a role into what is the risk of each patient. Their exercise capacity, and also labs, and importantly, albumin. You know, what is that nutritional status? So, for our patient, as you can see here, they didn't have no comorbidities. There were sort of a modest exercise capacity, and the labs were okay. So, they were normal, as far as we know. Here are the surgery-related factors. So, whether it was emergent versus elective, what is the risk of surgery? Low, intermediate, or high risk, and we're going to go through that in the next slide. Open versus laparoscopic and prolonged surgeries, which is defined as any surgery that's over three hours. So, for our patient, this was an elective procedure, which we'll see that it's an intermediate risk for surgery. They said that we could either recommend open versus laparoscopically, and it's a short duration surgery, for the most part. So, this is both from an anesthesia and surgical risk calculator. As you can see here, things that are low risk are like eye procedures, and very, very super skin procedures. Intermediate risk are things that are abdominal, or that are non-thoracic, and then the higher risk are things that are now vascular or thoracic in nature. So, our patient is in this intermediate risk category, which is our cholecystectomy. So, very important thing to think about, that I really did not appreciate until actually I came to do this talk, is how is the technical differences between an open and a laparoscopic surgery. We always think that laparoscopic is better, right? Smaller incision, patients get recovery faster, they're able to go back to their lives much faster. However, when you think about this, and you then put it into the context of the pulmonary hypertension physiology, this is a procedure in which you have to inflate their belly, and often they need to be on Trendelenburg, because they need to have all their organs exposed. So, with that, you put in a lot of CO2 in their belly, which displaces the diaphragm, and that's going to increase their inspiratory pressures, and that may affect your hemodynamics. Not only that, then that CO2 may be now systemically absorbed, and that's going to increase your pulmonary vascular resistance, which increases your RV afterload. So, in a study that I found that included 180,000 patients that all underwent laparoscopic surgery, of which about 1,400 of them had pulmonary hypertension, their odds risk of complications was 3.7. So, it's really, really much higher than the population at large. So, I think it is something to really consider, and I actually had to call one of my cardiac anesthesiology colleagues, because I was like really mind blown by this. I was like, is this a thing? Is this something that you guys talk about? And it is, right? So, very importantly, I think, to highlight, and I'm sure this is going to be a theme for our talks, is that multidisciplinary decision is really key, right? So, you want the PH specialist to talk to your anesthesiologist, preferably a cardiac anesthesiologist, to talk to the surgery team, to also kind of come up with a post-op immediately, a critical care plan in place, so that everything goes as smoothly as you can. And another important thing is, do every patient need to have repeat hemodynamics right before surgery? I think that there is very little literature in this, but this study that was out of Hopkins, what they did, they included 150 patients, and they tried to create a specific pulmonary hypertension perioperative risk score to classify patients into low, intermediate, or high risk of complication. And they dreaded out until a year out, which I think was a very important outcome, as opposed to just like an immediately post-op complication. And they evaluated different characteristics, including clinical functional status, like exercise, echo, and hemodynamic parameters. And they came up with two groups. So, here's the non-invasive parameters, and then they also did an invasive and non-invasive parameters. So, you can see in the non-invasive ones, you have your WHO functional class, six-minute walk, and BNP. And then in the invasive, they substituted the BNP for right atrial pressure and cardiac index. So, it turns out, really crazy, that in this study, it turns out that non-invasive parameters were able to predict 70% reduction in the post-op complications, which was, at least in here, superior than both invasive and non-invasive. So, I think thought provoking. I'm not saying this is now guidelines, but I think it's important to consider that maybe not every patient needs to have a repeat invasive hemodynamic test before surgery. So, here's what I would do on this patient. So, let's just maybe go to the highlights first, and I think that we remind everyone of how this patient is. Again, newly diagnosed, idiopathic. Here are hemodynamics. Here are her labs. I showed you a reveal score. And here's what I would do. So, I think that I have to talk to the surgeon first, and I would say, hey, surgeon, does this surgery really need to be in six weeks, or can we delay it like three to six months? And if the question, if the answer is no, it needs to be done in six weeks, then I probably would go ahead and further be more aggressive and add IV or subcutaneous therapy to this newly diagnosed patient, because I don't think that your oral therapy is probably going to be able to get you there by six weeks. And then after that, if things, you know, if the patient responds well, then perhaps going with an open approach may be reasonable. If the answer is yes, we can delay surgery. So, then at the three to six months, then we will be able to re-evaluate these parameters, re-evaluate functional class, repeat an echo, repeat a walk, get labs with a pro BNP. And if those are improved, then maybe consider doing a right heart cath, and if the right heart cath shows that there's hemodynamic improvement, then go for laparoscopic cholecystectomy, which I think probably be the safest thing for the patient. However, if their parameters are not improved in the three to six months, then I would then at the time add that third medicine, and I guess go back to the original question. Can we then defer the surgery another three to six months, or do we need to go and do the surgery right then and then that perhaps would just go back to, you know, re-evaluation? So, here is what you guys get to vote, and let us know what you think. So, is it going to be repeat right heart cath with improved hemodynamics? Is it going to be lower risk score needed first before surgery clearance? Is it going to be a laparoscopic cholecystectomy six weeks? Is it going to be an open cholecystectomy in six weeks? Oh, okay. So, yeah, 28 of you, 76% said lower risk score, and that is exactly what I chose as well, because I do think that there is not necessarily a single path to follow. You just have to know that the patient needs to show improvement. So, to summarize, these are my recommendations on how to minimize pulmonary hypertension perioperative risk. So, preoperatively, what do you want to do? Optimize facial dilators and diuretics as you can. Optimize their functional status, whether that is putting them on, making sure they exercise or rehab. Communication with providers so you have a plan in place, and I do definitely recommend that the surgery, especially for group 1 PAH patients, be done at an expert center, not because of the risk, but also because availability of medications and drugs that you may need along the way. Interoperatively, avoid intubation if necessary. I do still think that, you know, considering an alternative approach other than general anesthesia if it's possible. Cardiac anesthesia to be able to discuss what are the drugs that you're going to use for induction. Minimize IV fluids during surgery. And then postoperatively, restart pulmonary hypertension as soon as possible, and if you know that, for example, in this patient that's going to have a cholecystectomy that is not going to be able to start oral medicines right away, that you have a plan in place. Are we going to do IV therapy or inhaled therapy? What are the options for us? And very importantly, don't forget about DVT prophylaxis because it does minimize the risk of complications further. And I thank you with that. Thank you so much, Arun, and aloha, everyone. Good morning. While I'm waiting for my slides to pull up, unfortunately, you know, renal disease and renal, end-stage renal disease, pulmonary hypertension is far more common than, you know, pulmonary arterial hypertension. And yet, you know, when we talk about, you know, perioperative optimization, we don't have a lot of data. You know, so my hope is in going over some of the literature, I can give you just my perspective in how I deal with, you know, optimizing these patients and consideration for early kidney transplant in these patients. Because, you know, I think in literature today, as many as 14% of the U.S. adult population now has CKD, right? And so, you know, this is a really important topic. But I'm going to start with the case. And your QR code earlier is supposed to still work, right? Like, they don't have to navigate out. But, you know, so the case is, we have a 51-year-old male with end-stage renal disease from type 2 diabetes. And he gets hemodialysis via an AV fistula. On echocardiogram, there is some degree of right ventricular dysfunction. You know, there's some dilation of his RV. There's dilation of both atria, the right atrium, the left atrium. His tapsy is okay. And then there's, you know, a moderate elevation of his RV systolic pressure and a small pericardial effusion. A right heart catheterization is done, and you have, you know, a severely elevated mean PA pressure, a high right atrial pressure, a wedge of 14. You know, and there's no hemodynamic, like, fluid saline loading here. So you don't know if there's any occult LV dysfunction here. But, you know, this is resting right heart cath values, right? And you have a thermodilution of 7.2, an index of 3.8. Oops. This is sensitive. All right. And WHO functional class 2. And his AV fistula flow was measured via Doppler at 2.2 liters per minute. He's been on dialysis for three years. So the offers available to the audience include, you know, would you repeat, given these hemodynamics, would you repeat the right heart catheterization and then occlude the fistula, right? And the occlusion study can either be done through a sphygmomanometer, right, where you, you know, you go at 50 millimeters mercury above their, you know, mean systolic pressure prior to transplant looking for a hemodynamic change. Would you say, hey, look, they're WHO group 2. They seem to be okay. RV dysfunction isn't, quote unquote, that bad. You know, maybe I can just clear them for renal transplant, right? A few years ago, this would have barely made the PVR cutoff for pH. Would you try PDE5 inhibitor targeted therapy to try to improve hemodynamics? Is there data to show that that, you know, is helpful, harmful, or would you preemptively close this fistula and repeat the right heart cath prior to transplantation? And thankfully, there are no maybe nephrologists in the room because this is a very controversial topic. I'm going to skip over because that's going to hopefully, hopefully, you know, I can convince some of you otherwise. So the prevalence of pulmonary hypertension is so high in patients with end-stage renal disease. I almost think of it as an inevitable complication of, you know, end-stage renal disease. It's almost a natural occurrence. And it's so prevalent that the screening guidelines for, you know, pre-kidney transplant include looking for pulmonary hypertension with an echo if you have risk factors, things like sleep apnea or risk factors for group one pulmonary hypertension. And they include moving on to a right heart cath if you have RV pressures, you know, reaching 45 millimeter mercury or, you know, signs of RV pressure overload. And they say if you do have right heart catheter-defined pH, you know, a referral to a pH expert is ideal. And the KDGO guidelines actually say, you know, ideally patients should be referred to a cardiologist at least. And then they say, you know, maybe a pH expert. So for the pulmonologist in the room, you know, maybe we need to have a talk with the people who make the guidelines. But that's another talk. Okay. And these patients, these patients have, you know, poor prognosis when you know they develop pulmonary hypertension. And, you know, remember that a lot of the studies in end-stage renal disease pH is defined echocardiographically. So, you know, most of the time these patients were, you know, they had pulmonary arterial systolic pressures of more than 35. And, you know, the adjusted all-cause mortality risk in these patients was up to 38% with close to a fourth of them with increased risk of cardiac events, MIs, heart failure exacerbations. And we know that this was far more prevalent in those that got HD than PD. And that's really an important key feature that I'd like to point out. So when I was going through this, I was like, how would I systematically approach looking at whether a patient can be cleared for a kidney transplant? And I wanted to adopt, you know, the proposed perioperative risk stratification of the ACC in 2023 where they try to break it down into, you know, three steps, classifying, you know, your pH hemodynamics, going over, you know, a pre-op risk assessment, and then optimization of pH prior to surgery, knowing that in end-stage renal disease pH, you know, the likely hemodynamic etiology is going to be one, two, three, if not all of these. And I apologize, so the PPR cutoffs are now, you know, greater than or equal to two Woods units. But for end-stage renal disease pH, right, you can have any combination of this. In our case, right, this patient has right heart catheterization hemodynamics that were consistent with pre-capillary pH. But more commonly, patients predominantly have who group two disease. So, you know, isolated post-capillary pH, and eventually over time, they get pulmonary vascular remodeling, either due to concomitant insults or pulmonary over-circulation with high cardiac output states. And this is sort of like a way to kind of think about it, right? When you develop end-stage renal disease, it usually starts with a great degree of LV dysfunction, arterial stiffness. And the normal physiology is you have an increase in systemic vascular resistance. You get increased LV overload, LV stiffness, LV hypertrophy. These patients are normally hypertensive. They have, you know, hypertrophic cardiomyopathies. And, you know, they're mostly group two. And you add to that the insult of RV, increased RV circulation with things like an AV fistula or a high cardiac output state because these patients are anemic. And so you add more and more insults to the RV. Eventually, patients can also develop microthrombi, vascular calcifications, inflammation. These patients can develop uremic endothelial dysfunction. And all of these things end in a cascade of increased pulmonary vascular resistance, increased pulmonary vascular remodeling. And I haven't even added the fact that there's an increased prevalence of sleep apnea in this population of patients. You know, and so when you start to see trouble, when these patients are referred to a PH center, they're usually patients that now start to develop hypotension with their dialysis because their RV starts to fail. These patients are chronically on medidrin, you know, because, you know, after some point, the AV fistula then induces, you know, the low systemic vascular resistance, you know, because of neurohormonal factors increase in, you know, your sympathetic system. All right. So when I think about the pre-op risk assessment, it's not as elegant as, you know, the data that we have for pulmonary arterial hypertension, right? Because when we look at PH risk evaluation, a lot of our measures for how well are these patients doing in end-stage renal disease is clouded by the end-stage renal disease. So things like, you know, exercise capacity, their functional class, all of that, you know, kind of goes out the window. Can you rely on a BNP? Can you rely on, you know, traditional factors that increase risk in pulmonary arterial hypertension? Not as much. And because this isn't something that is as studied, we don't really know, you know, what to lean on outside of hemodynamics when we're treating these patients. And so you either lean towards being very, very conservative, very, very careful, and you're, you know, you are preventing these patients from getting renal transplants, or throwing caution to the wind and saying, hey, you know, this should be okay. These patients might do okay. So, you know, what does the data really tell us? In these kidney transplant patients, we know that they do better with transplant than without. So for patients with pulmonary hypertension, by echo, it is still far better to get a kidney transplant than to die on the wait list when you have, you know, pulmonary artery systolic pressures between 35 to 40 millimeter mercury by echo. And the closer you get to 50 and 55, the worse the outcomes. So there's increased risk of delayed graft dysfunction or failure, which was defined as, you know, dialysis within seven days post-transplant. And there's increased risk of death-sensored graft failure, the closer you get to that 50 millimeter mercury mark. But again, survival was better than when you were waiting on the kidney transplant wait list. And in this population of patients, you know, these, a lot of these patients didn't use to get right heart caths. But they looked at a population of patients who were right intraoperatively got right heart caths, and they saw that if you had a PA systolic pressure of more than 35, your overall survival was worse. So what are the things you can do? Well, you can figure out the hemodynamics and really tackle the main etiology. But which of these can we really modify in these patients? Can you do PDE therapy when you have a degree of LV dysfunction? Probably not. Can you, can you mediate things like sleep apnea? That's probably much easier. Can you fix valvular heart disease? Can you optimize medication for HFPEF? You can try all of that. But the one thing that I wanted to sort of leave you with is really looking at the impact of AV fissure, AV grafts on RV dysfunction and survival. So this is a really elegant study where they looked at changes in RV structure and function two to three months after putting in an AV fissure, AV graft. And you can see that pre- and post-AV fissure creation, you can already see changes in your RV fractional area change. You can see changes echocardiographically. Some of the literature even says within 10 to 14 days, you can already see echocardiographic changes of RV dysfunction. And we know that this impacts patient survival. But what I'd like to point out is this curve on the right side where if there is RV dilation after AV fissure, these are actually the patients that do pretty poorly over time. And so I bring us back to, you know, this case and my approach and my way of thinking of this patient. And I, you know, highlighted clinical features that would make me think, hey, this is what's important, right? So the TAPC is not so bad. RVSP is high. And the hemodynamics suggests that it's precapillary. But the most important key feature in this case to me is this patient's AV fissure flow, right? So 2.2 liters per minute. And we know that in patients that have high output heart failure due to AV fissure, and they, in a lot of the literature, they define this as more than 1.5 liters per minute. And the closer you are to 2 liters per minute, the worse the outcomes. We know that these patients do poorly. But when you look at these static signs, echo signs, right heart catheterization signs, I think the most important thing that I think about is the cardiopulmonary recirculation ratio, right? And that's around 30%. And that's really the relative cardiac output to the flow in your AV fissure. Because you're very tempted to look at these static numbers and say, hey, a cardiac output of 7.2 may not seem so bad. But when you're thinking about the relative decrease in that patient's cardiac output, I bring you back to that physiology slide that I have. You know this patient is going to be in trouble. And maybe not now, but like Dr. Belinda Lebron-Rivera's slide, you know, kind of emphasizes, it's looking at what does the landscape look like? What's going to happen when you put this patient, you know, under general anesthesia? They get volume overloaded. You're already having a hard time dialyzing these patients consistently because they have a degree of RV dysfunction. They're already hypotensive, right? So this patient's SVR is already, you know, in the 800s. So what is the one thing that I can think of to do? And this is a very controversial thing to do. It's really can this fissure or should this fissure be ligated? So I'm going to leave you with, you know, one of my favorite quotes, really. Like, failing to plan is planning to fail. And it's not an easy decision. And it's not a decision to be made alone. So if I could borrow her slide on, you know, using your multidisciplinary team, I would include cardiothoracic anesthesia. Your cardiologists, get them to back you up because your nephrologist is going to say, You cannot ligate this fissure. They're going to negotiate and try to band it. And I don't know about you, but this is always an ongoing, not fight, but discussion about what is going to help a patient. So to me, what I'd like you to think about when you select, ask my sharks, is I'd like you to think about in this particular case, how can we use our understanding of hemodynamics to really think about how we can optimize this patient. And it's not the right answer for every end-stage renal disease patient. And I don't even know honestly with these choices if there is a right answer, but I know that if you put them on PDE-5 with these hemodynamics, they may not do well. All right. All right, thank you. All right, moving on to our last case. I'm pleased to introduce Dr. Kay, who will be talking about knee replacement in chronic thromboembolic pulmonary hypertension. Hi, everyone. These have been some fantastic cases. I think I got the easy one with inoperable CTEF and elective knee replacement. So I'm Dana Kay coming from Cincinnati, Ohio. I have no disclosures. This is the same QR code you've been using. So our case is a 58-year-old female with osteoarthritis and inoperable CTEF due to distal lesions that is seeking a knee replacement. She's on systemic anticoagulation with a PIXA band. And her CTEF is being treated with sildenafil and masatantin. The last right heart cath was from two years ago with a PVR of 4.6 woods units. And an echocardiogram, her most recent echocardiogram was done eight months ago, which showed normal RV function and structure and an RVSP of 38 millimeters of mercury. The patient's dyspnea is only moderate with exertion and she falls into the functional class two. And orthopedic surgery hopes to do a knee replacement within two months. The other comorbid conditions are hypertension, diabetes, CKD, and her current reveal 2.0 risk score is six. So we're gonna talk about what is the best answer choice. So these are the answer choices. You can feel free to answer now or just we'll move forward. So before answering the question, I'm gonna talk about preoperative risk assessment and CTEF, optimizing pulmonary hypertension prior to surgery. And then we're gonna talk about some important factors in the intraoperative and postoperative management of these patients. So again, to review, this is a patient that has inoperable CTEF. She's on dual vasodilator therapy on sildenafil and masatentin. Not quite sure why sildenafil, but that's the case. She's on anticoagulation, functional class two, the typical comorbidities of diabetes, hypertension, and kidney disease. I'm assuming the right heart cath two years ago was at time of diagnosis where she had a PBR of 4.6 woods units. And her echocardiogram eight months ago looked pretty good, normal functioning RV with a reasonable RVSP of 38 millimeters of mercury and a reveal score of six. I just put that chart there so you can remind yourself about the reveal scores and their related one year survival. So she's in the lower risk category. So let's talk about preoperative risk stratification and non-cardiac surgery. We don't always have specific data for CTEF. So I'm gonna review some of the studies that Blynda already mentioned, which are fantastic studies. So we know that in patients with pulmonary hypertension, they have higher morbidity and mortality when they're undergoing surgery, and they have an increased risk for heart failure, cardiac arrhythmias, hemodynamic instability, respiratory failure, and prolonged hospitalizations. I'll again, bring your attention to the study done by Smewits and colleagues, which looked at perioperative major adverse cardiovascular events in 17 million hospitalizations in the US between 2004 and 2014, and found that patients that had a diagnosis of pulmonary hypertension had four times the complications. And even when they adjusted for the demographics and the clinical characteristics, patients with pH in this population still had two to three fold increase in major adverse cardiovascular events. Additionally, I love that chart that just shows you that the number of patients with pulmonary hypertension that required surgery increased over the years. In 2004, it was 0.4%. In 2014, it was 1.2%, and that just tells you that this is a problem that we're gonna see over and over again, and more and more of it, and I'm sure a lot of practitioners out there will have to deal with this evaluation. Another great study is one done by Merritt and colleagues, which showed that patients with PAH who underwent non-cardiac surgery at a pH center still had 6.1% complication rates, and a 2% mortality when it came to non-emergent procedures. So again, pH patients are at high risk of complications and mortality when it comes to surgery, and that's why it's so important to go and do a very thorough preoperative evaluation. So there are several PAH risk assessment tools that help us better understand the patient's disease state and alert us to whether or not we need to change management of their pulmonary hypertension before they undergo the stress of a procedure. The European ESC-ERS risk assessment and the REVEAL risk score are two that have been studied to some degree in medically-managed CTEF, and, oop, let me go back, sorry. And, you know, I've just highlighted there that the information that they require to use the tools are just information you can get through a good physical history, a six-minute walk test, lab work, and right heart cath and echocardiogram. And then, of course, there are additional pulmonary risk assessment tools like the ERISCAT and the GUPTA calculator for post-operative respiratory failure that can also help optimize our patients further. So to go into a little bit more detail on some of the assessment scores that have been evaluated in medically-managed CTEF patients, Del Coy and colleagues studied the ESC-ERS abbreviated risk stratification score using patients from the Compera registry, and they found that the functional class, the six-minute walk distance, the right atrial pressure, and the cardiac index were independent prognostic factors, and that the overall survival of these patients at one year was 92%, at three year was 75%, and at five years it was 60%, with an obvious difference in survival based on which risk category they fell into, as you can see in that graph. Benz and colleagues in 2018, during their study looking at the effect of Rio Ciguad and the reveal risk score, also looked at the utility of the reveal risk score at predicting survival and clinical worsening using a post hoc analysis of the CHESS-1 and CHESS-2 data, and they found that the reveal risk score was significantly associated with survival, and with clinical worsening-free survival at two years as well. So using the risk stratification tool involves using hemodynamic parameters, such as cardiac output, cardiac index, and right atrial pressure, and this information can either be measured by a right heart cath, or it can be estimated with an echocardiogram. So overall we know that the right heart catheterization is the gold standard for evaluating hemodynamics in PH patients. It is a relatively safe procedure with complication rates less than 1%. It often requires holding anticoagulation because it is an invasive procedure, and it can be time-consuming because the patients have to go in for the procedure, do the pre-procedural and post-procedural protocols, but it tends to give the more accurate measured numbers. When it comes to echocardiogram, it's great for looking at RV size and structure, the presence of pericardial effusions, and estimating the pulmonary artery systolic pressure, but as Austin and colleagues showed in their study, as part of, while they were looking at echo-measured right atrial pressure and mortality in PH patients, they found that the accuracy of an estimated right atrial pressure on echocardiogram was only 63 to 68% compared to when measured with a right heart cath. And also in the literature, there's really, it doesn't show good accuracy when comparing estimated cardiac output by echocardiogram compared to when it's measured with thermodilution in the right heart cath. So it's important to use accurate information when using the risk stratification tools in order to come up with the most accurate risk assessment. If you're just using numbers that are estimates and that may not be accurate, well, that kind of just defeats the point here. What the risk assessment tools help us understand is the patient's disease state and whether further optimization of the medical management is needed. The goal is to have the patient in the lowest risk, so in the green areas. When it comes to the reveal score, you want them to have a score of less than six and have the lowest risk with the best one-year survival, and same with the ESC-ERS tool. You want them to end up in the green, in the low-risk area. And if we see that the patients are intermediate or higher risk, then we need to start thinking about how we can optimize their care. And there are several things that we can think about, such as increasing their vasodilator therapy, changing their vasodilator therapy, making sure that they're euvolemic and that they're on a proper diuretic regimen, looking at their medication regimen and making sure that they're not on any medications that are counterproductive in terms of their pH management. When it comes to anticoagulation, patients with CTEF are recommended to be on lifelong anticoagulation in order to prevent recurrent VTEs, and also to prevent in situ pulmonary artery thrombosis. And so it's important to limit anticoagulation interruptions. The preferred agent is obviously a vitamin K antagonist, but DOACs are often used as well. So, and especially in a case like this, when you have a patient undergoing knee arthroplasty, we know that their risk for VTE is higher, and it's very important to make sure that you're not interrupting their anticoagulation much. When it comes to intraoperative risk management, whenever it's possible, like it's been said before, we like to have this done with the presence of cardiac anesthesia, and preferably at a pulmonary hypertension center. Spinal anesthesia has been shown in multiple studies to result in less hemodynamic instability. The study by Messina and colleagues showed that general anesthesia results in more significant reduction in cardiac index and mean atrial pressure compared to spinal anesthesia. And I'd like to bring your attention to the numbers. Of course, you'll see that there's more of a difference in the general anesthesia when it comes to cardiac output, cardiac index and mean PAP, but still with spinal anesthesia, you still do have those shifts in hemodynamics. And so just using spinal anesthesia is not enough, and you still need to make sure that those patients have had proper preoperative assessment and optimization of their pulmonary hypertension before even getting spinal anesthesia. Now, in the postoperative period, as we're rounding third and heading home, we're not done yet. We still gotta keep in mind a couple of important management factors, such as making sure the patient stays uvulemic, avoiding fluid boluses, because it causes hemodynamic shifts, avoiding beta blockers and calcium channel blockers, and not holding the pulmonary hypertension medications. Even if the patient has some difficulty with hemodynamic stability, the last thing you wanna do is hold their vasodilator and stress out that RV even more by increasing the RV afterload. Extubating early is useful because it limits how much sedation you use as it causes shifts in blood pressure, limiting anticoagulation as much as possible, interruption of anticoagulation as much as possible, and of course, working with your pulmonary hypertension team to have that multidisciplinary approach to solve problems. Now, going back to the question, oh. Well, I don't know if you can cast your vote, but it's a little shit, but you can go ahead and ignore the colors there. They mean nothing. They mean nothing. I'll stay here, and I like the way these numbers look. So my answer was yes, repeat the right heart cath prior to operative clearance because you want the most accurate hemodynamics to use in your risk stratification tools. Of course, using spinal anesthesia is great, and you should always speak with your anesthesia team to see if there are local forms of anesthesia or spinal anesthesia available for the procedure you want to do, but just using spinal anesthesia alone is not enough to clear the patient for surgery. Of course, for a patient with CTEF, we need an anticoagulation bridge plan, especially in the case of undergoing knee arthroplasty and the elevated risk for VTE, but just having an anticoagulation bridging plan is not enough to clear them for surgery, and like I said, I would prefer a right heart cath over an echocardiogram just because I want the most accurate information when evaluating their risk for the OR. Thank you, guys.

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