The principal consideration is to
prevent increases in pulmonary hypertension that may result in right-heart
failure. Continuous monitoring of arterial and central venous pressure,
electrocardiography, and pulse oximetry are recommended for every anesthetic
procedure. The use of a pulmonary artery catheter is controversial.
Transesophageal echocardiography is useful. The choice of anesthetic
technique and drugs per se is of secondary importance and should be governed
by individual preferences. Avoid known factors that may exacerbate pulmonary
hypertension—hypoxemia, hypercarbia, acidosis, high airway pressures,
positive end-expiratory pressure, stress, and pain. Tracheal intubation
increases positive airway pressure and causes right-heart strain. A
“stress-free” anesthetic with controlled ventilation, gentle intubation,
and continuous hemodynamic monitoring would provide ideal conditions. An
appropriate regional anesthetic technique performed with care to avoid any
hemodynamic disturbances, and with deafferentation of all noxious input is
equally satisfactory.