Pulmonary hypertension is a major reason for elevated perioperative morbidity and mortality, even in noncardiac surgical procedures. Patients should be thoroughly prepared for the intervention and allowed plenty of time for consideration. All specialty units involved in treatment should play a role in these preparations. After selecting each of the suitable individual anesthetic and surgical procedures, intraoperative management should focus on avoiding all circumstances that could contribute to exacerbating pulmonary hypertension (hypoxemia, hypercapnia, acidosis, hypothermia, hypervolemia, and insufficient anesthesia and analgesia). Due to possible induction of hypotonic blood circulation, intravenous vasodilators (milrinone, dobutamine, prostacyclin, Na-nitroprusside, and nitroglycerine) should be administered with the greatest care. A method of treating elevations in pulmonary pressure with selective pulmonary vasodilation by inhalation should be available intraoperatively (iloprost, nitrogen monoxide, prostacyclin, and milrinone) in addition to invasive hemodynamic monitoring. During the postoperative phase, patients must be monitored continuously and receive sufficient analgesic therapy over an adequate period of time. All in all, perioperative management of patients with pulmonary hypertension presents an interdisciplinary challenge that requires the adequate involvement of anesthetists, surgeons, pulmonologists, and cardiologists alike. 1. Background Pulmonary hypertension represents an important risk factor for increased perioperative morbidity and mortality. Stress, pain, ventilation, and surgery-related inflammation can further increase pressure and resistance within the pulmonary arteries and cause right-sided heart failure. Ramakrishna et al. have described a number of independent factors leading to an increased perioperative risk for patients with pulmonary hypertension. Conditions that caused one or more perioperative complications in 42% of all patients were heart failure of NYHA class II or higher, a history of pulmonary embolism, high-risk surgery (e.g., thoracic or major abdominal surgery), and an anesthesia duration of more than 3 hours [1]. The literature reports a perioperative mortality of 7–24%—depending on the primary disease and the type of surgical intervention—with the highest risk for pregnant women and patients undergoing emergency interventions [1–5]. In a recently published study, Kaw et al. examined the clinical progression of 96 patients with pulmonary hypertension who underwent a noncardiac surgical procedure. The PH
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