Pre-operative Right Heart Echocardiography in Obese Chronic Obstructive Pulmonary Disease Patients Presenting for General Anesthesia: A Case Series on the Role of Ventriculo-Arterial Coupling

The prevailing right heart functional milieu is determined by the ventricular performance in relation to the afterload served by the pulmonary artery systolic pressure (PASP). The importance of the same is being increasingly recognized for the conduct of general anesthesia (GA), however mandating an improved focus in the subset expected to have baseline PASP elevation. We report the perioperative course of 10 obese patients with chronic obstructive pulmonary disease, in whom the pre-operative PASP in mmHg exceeded the tricuspid annular plane systolic excursion (TAPSE) (TAPSE, in mm), amounting to TAPSE/PASP ratio <1, who were administered GA for elective non-cardiac surgery. A total of nine patients manifested systemic arterial hypotension at anesthetic induction. A couple of patients with a pre-induction TAPSE/PASP ratio <0.55 mm/ mmHg (i.e., right ventricle-pulmonary artery uncoupling) manifested the maximum % decline in the mean arterial pressure till 10 min post-induction. Further, five out of the ten patients required ≥3 vasopressor boluses for the maintenance of intraoperative hemodynamics. The patient with the lowest pre-induction TAPSE/PASP value (despite normal baseline renal function) developed post-operative acute kidney injury, however, having had simultaneously required intraoperative blood transfusion. Ventriculo-arterial (un)coupling at the level of the right heart, assessed by echocardiography, can be a valuable addition to pre-operative risk-stratification in the predilected non-cardiac surgical cohort receiving GA, mandating future research in the subject.