{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T12:02:20Z","timestamp":1790596940969,"version":"4.1.0"},"reference-count":51,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T00:00:00Z","timestamp":1790553600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:p>Pulmonary hypertension increases perioperative risk because anesthesia, positive-pressure ventilation, bleeding, and surgical stress can rapidly disturb coupling between the right ventricle and the pulmonary circulation. Pulmonary artery pressure alone cannot distinguish successful unloading from loss of right-ventricular output. This narrative review integrates contemporary guidance, noncardiac surgical cohorts, right-heart physiology, echocardiography, and critical-care evidence and then proposes a provisional five-domain model. The domains are pulmonary vascular load; right-ventricular reserve and ventricular-arterial coupling; systemic perfusion; effective preload and venous congestion; and forward flow and oxygen delivery. The underlying physiology and most component management principles are established; the novel contribution is their longitudinal organization into pressure-flow trajectories, provisional dominant phenotypes, and timestamped intervention-response pairs. Evidence provenance is labeled as guideline or consensus, direct perioperative clinical data, extrapolated physiologic or critical-care evidence, or an unvalidated framework hypothesis. A measurement hierarchy separates quantitative cardiac-output estimates from stroke-volume trends and from downstream perfusion surrogates. Provisional classification requires a core directional pattern plus corroboration from independent domains and permits mixed or indeterminate states. Disease group remains decisive because the same trajectory may imply different hazards in precapillary, postcapillary, lung-disease, or thromboembolic pulmonary hypertension. During controlled instability, one small matched intervention can test the working mechanism; during immediately life-threatening deterioration, parallel resuscitative actions take precedence. The proposed model must demonstrate reproducible classification and incremental value beyond contemporary clinical risk assessment, right-ventricular function, biomarkers, procedure characteristics, and conventional monitoring before it is used as a treatment algorithm.<\/jats:p>","DOI":"10.3389\/fmed.2026.1972194","type":"journal-article","created":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T11:41:20Z","timestamp":1790595680000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Pressure-flow discordance in perioperative pulmonary hypertension: a mechanism-based review and provisional five-domain right-heart model for noncardiac surgery"],"prefix":"10.3389","volume":"13","author":[{"given":"Budanbaila","family":"La","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, The Affiliated Hospital of Inner Mongolia Medical University","place":["Hohhot, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yanyan","family":"Bai","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Hohhot Maternal and Child Health Hospital","place":["Hohhot, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yiri","family":"Du","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, The Affiliated Hospital of Inner Mongolia Medical University","place":["Hohhot, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yi","family":"Qiu","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, The Second Affiliated Hospital of Inner Mongolia Medical University","place":["Hohhot, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ling","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, The Affiliated Hospital of Inner Mongolia Medical University","place":["Hohhot, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,28]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"2401324","DOI":"10.1183\/13993003.01324-2024","article-title":"Definition, classification and diagnosis of pulmonary hypertension","volume":"64","author":"Kovacs","year":"2024","journal-title":"Eur Respir J"},{"key":"B2","doi-asserted-by":"publisher","first-page":"3618","DOI":"10.1093\/eurheartj\/ehac237","article-title":"2022 ESC\/ERS guidelines for the diagnosis and treatment of pulmonary hypertension","volume":"43","author":"Humbert","year":"2022","journal-title":"Eur Heart J"},{"key":"B3","doi-asserted-by":"publisher","first-page":"2401325","DOI":"10.1183\/13993003.01325-2024","article-title":"Treatment algorithm for pulmonary arterial hypertension","volume":"64","author":"Chin","year":"2024","journal-title":"Eur Respir J"},{"key":"B4","doi-asserted-by":"publisher","first-page":"2401344","DOI":"10.1183\/13993003.01344-2024","article-title":"Pulmonary hypertension associated with left heart disease","volume":"64","author":"Maron","year":"2024","journal-title":"Eur Respir J"},{"key":"B5","doi-asserted-by":"publisher","first-page":"2401200","DOI":"10.1183\/13993003.01200-2024","article-title":"Pulmonary hypertension associated with lung diseases","volume":"64","author":"Shlobin","year":"2024","journal-title":"Eur Respir J"},{"key":"B6","doi-asserted-by":"publisher","first-page":"2401294","DOI":"10.1183\/13993003.01294-2024","article-title":"Chronic thromboembolic pulmonary disease","volume":"64","author":"Kim","year":"2024","journal-title":"Eur Respir J"},{"key":"B7","doi-asserted-by":"publisher","first-page":"774","DOI":"10.1016\/j.bja.2021.01.005","article-title":"Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement","volume":"126","author":"Price","year":"2021","journal-title":"Br J Anaesth"},{"key":"B8","doi-asserted-by":"publisher","first-page":"1317","DOI":"10.1161\/CIR.0000000000001136","article-title":"Evaluation and management of pulmonary hypertension in noncardiac surgery: a scientific statement from the American Heart Association","volume":"147","author":"Rajagopal","year":"2023","journal-title":"Circulation"},{"key":"B9","doi-asserted-by":"publisher","first-page":"1135","DOI":"10.1016\/j.healun.2022.06.013","article-title":"ISHLT consensus statement: perioperative management of patients with pulmonary hypertension and right heart failure undergoing surgery","volume":"41","author":"McGlothlin","year":"2022","journal-title":"J Heart Lung Transplant"},{"key":"B10","doi-asserted-by":"publisher","first-page":"1302","DOI":"10.1183\/09031936.00089212","article-title":"Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey","volume":"41","author":"Meyer","year":"2013","journal-title":"Eur Respir J"},{"key":"B11","doi-asserted-by":"publisher","first-page":"1691","DOI":"10.1016\/j.jacc.2005.02.055","article-title":"Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality","volume":"45","author":"Ramakrishna","year":"2005","journal-title":"J Am Coll Cardiol"},{"key":"B12","doi-asserted-by":"publisher","first-page":"619","DOI":"10.1016\/j.rmed.2010.12.006","article-title":"Pulmonary hypertension: an important predictor of outcomes in patients undergoing non-cardiac surgery","volume":"105","author":"Kaw","year":"2011","journal-title":"Respir Med"},{"key":"B13","doi-asserted-by":"publisher","first-page":"1532","DOI":"10.1016\/j.amjcard.2019.02.006","article-title":"Cardiovascular outcomes of patients with pulmonary hypertension undergoing noncardiac surgery","volume":"123","author":"Smilowitz","year":"2019","journal-title":"Am J Cardiol"},{"key":"B14","doi-asserted-by":"publisher","first-page":"1506","DOI":"10.1053\/j.jvca.2019.10.059","article-title":"Outcomes after noncardiac surgery for patients with pulmonary hypertension: a historical cohort study","volume":"34","author":"Deljou","year":"2020","journal-title":"J Cardiothorac Vasc Anesth"},{"key":"B15","doi-asserted-by":"publisher","first-page":"00257","DOI":"10.1183\/23120541.00257-2021","article-title":"A novel approach to perioperative risk assessment for patients with pulmonary hypertension","volume":"7","author":"Hassan","year":"2021","journal-title":"ERJ Open Res"},{"key":"B16","doi-asserted-by":"publisher","first-page":"66","DOI":"10.1186\/s13741-023-00351-x","article-title":"Perioperative quality initiative consensus statement on perioperative assessment of right ventricular function","volume":"12","author":"Ibekwe","year":"2023","journal-title":"Perioper Med"},{"key":"B17","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1186\/s13741-024-00397-5","article-title":"Perioperative management of the vulnerable and failing right ventricle","volume":"13","author":"Arora","year":"2024","journal-title":"Perioper Med"},{"key":"B18","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1186\/s41073-019-0064-8","article-title":"SANRA\u2014a scale for the quality assessment of narrative review articles","volume":"4","author":"Baethge","year":"2019","journal-title":"Res Integr Peer Rev"},{"key":"B19","doi-asserted-by":"publisher","DOI":"10.1183\/13993003.01900-2018","article-title":"Pathophysiology of the right ventricle and of the pulmonary circulation in pulmonary hypertension: an update","volume":"53","year":"2019","journal-title":"Eur Respir J."},{"key":"B20","doi-asserted-by":"publisher","first-page":"266","DOI":"10.1186\/s13054-016-1440-0","article-title":"The right ventricle: interaction with the pulmonary circulation","volume":"20","author":"Pinsky","year":"2016","journal-title":"Crit Care"},{"key":"B21","doi-asserted-by":"publisher","first-page":"1436","DOI":"10.1161\/CIRCULATIONAHA.107.653576","article-title":"Right ventricular function in cardiovascular disease, part I: anatomy, physiology, aging, and functional assessment of the right ventricle","volume":"117","author":"Haddad","year":"2008","journal-title":"Circulation"},{"key":"B22","doi-asserted-by":"publisher","first-page":"1717","DOI":"10.1161\/CIRCULATIONAHA.107.653584","article-title":"Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure","volume":"117","author":"Haddad","year":"2008","journal-title":"Circulation"},{"key":"B23","doi-asserted-by":"publisher","first-page":"e578","DOI":"10.1161\/CIR.0000000000000560","article-title":"Evaluation and management of right-sided heart failure: a scientific statement from the American Heart Association","volume":"137","author":"Konstam","year":"2018","journal-title":"Circulation"},{"key":"B24","doi-asserted-by":"publisher","first-page":"1111","DOI":"10.1056\/NEJMra2207410","article-title":"Right ventricular failure","volume":"388","author":"Houston","year":"2023","journal-title":"N Engl J Med"},{"key":"B25","doi-asserted-by":"publisher","first-page":"e1304","DOI":"10.1161\/CIR.0000000000001422","article-title":"Advanced molecular, metabolic, and imaging approaches to characterizing right ventricular failure: a scientific statement from the American Heart Association","volume":"153","author":"Pullamsetti","year":"2026","journal-title":"Circulation"},{"key":"B26","doi-asserted-by":"publisher","first-page":"90","DOI":"10.1111\/bph.14866","article-title":"Right heart failure in pulmonary hypertension: diagnosis and new perspectives on vascular and direct right ventricular treatment","volume":"178","author":"Tello","year":"2021","journal-title":"Br J Pharmacol"},{"key":"B27","doi-asserted-by":"publisher","first-page":"e70004","DOI":"10.1002\/pul2.70004","article-title":"Non-invasive surrogates for right ventricular-pulmonary arterial coupling: a systematic review and meta-analysis","volume":"14","author":"Golbin","year":"2024","journal-title":"Pulm Circ"},{"key":"B28","doi-asserted-by":"publisher","first-page":"00685","DOI":"10.1183\/23120541.00685-2024","article-title":"Right ventricular-pulmonary arterial coupling predicts mortality in precapillary pulmonary hypertension","volume":"11","year":"2025","journal-title":"ERJ Open Res"},{"key":"B29","doi-asserted-by":"publisher","first-page":"141","DOI":"10.1016\/j.echo.2025.01.006","article-title":"Guidelines for the echocardiographic assessment of the right heart in adults and special considerations in pulmonary hypertension: recommendations from the American society of echocardiography","volume":"38","author":"Mukherjee","year":"2025","journal-title":"J Am Soc Echocardiogr"},{"key":"B30","doi-asserted-by":"publisher","first-page":"e351","DOI":"10.1161\/CIR.0000000000001285","article-title":"2024 AHA\/ACC\/ACS\/ASNC\/HRS\/SCA\/SCCT\/SCMR\/SVM guideline for perioperative cardiovascular management for noncardiac surgery","volume":"150","author":"Thompson","year":"2024","journal-title":"Circulation"},{"key":"B31","doi-asserted-by":"publisher","first-page":"3826","DOI":"10.1093\/eurheartj\/ehac270","article-title":"2022 ESC guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery","volume":"43","author":"Halvorsen","year":"2022","journal-title":"Eur Heart J"},{"key":"B32","doi-asserted-by":"publisher","first-page":"607","DOI":"10.1186\/cc3877","article-title":"Clinical review: positive end-expiratory pressure and cardiac output","volume":"9","author":"Luecke","year":"2005","journal-title":"Crit Care"},{"key":"B33","doi-asserted-by":"publisher","first-page":"475","DOI":"10.1136\/adc.80.5.475","article-title":"Cardiovascular effects of mechanical ventilation","volume":"80","author":"Shekerdemian","year":"1999","journal-title":"Arch Dis Child"},{"key":"B34","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1097\/MCC.0b013e328342722b","article-title":"Acute respiratory distress syndrome, mechanical ventilation, and right ventricular function","volume":"17","author":"Bouferrache","year":"2011","journal-title":"Curr Opin Crit Care"},{"key":"B35","doi-asserted-by":"publisher","first-page":"930","DOI":"10.1097\/ALN.0000000000000430","article-title":"Vasoconstrictor responses to vasopressor agents in human pulmonary and radial arteries: an in vitro study","volume":"121","author":"Currigan","year":"2014","journal-title":"Anesthesiology"},{"key":"B36","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1046\/j.1365-2044.2002.02324.x","article-title":"The effect of phenylephrine and norepinephrine in patients with chronic pulmonary hypertension","volume":"57","author":"Kwak","year":"2002","journal-title":"Anaesthesia"},{"key":"B37","doi-asserted-by":"publisher","first-page":"1035","DOI":"10.1097\/01.CCM.0000120052.77953.07","article-title":"Effects of norepinephrine and dobutamine on pressure load-induced right ventricular failure","volume":"32","author":"Kerbaul","year":"2004","journal-title":"Crit Care Med"},{"key":"B38","doi-asserted-by":"publisher","first-page":"1381","DOI":"10.1007\/s12630-023-02520-4","article-title":"The perioperative use of inhaled prostacyclins in cardiac surgery: a systematic review and meta-analysis","volume":"70","author":"Marcus","year":"2023","journal-title":"Can J Anaesth"},{"key":"B39","doi-asserted-by":"publisher","first-page":"1316","DOI":"10.1161\/CIRCULATIONAHA.122.062464","article-title":"Inhaled epoprostenol compared with nitric oxide for right ventricular support after major cardiac surgery: the INSPIRE-FLO randomized trial","volume":"148","author":"Ghadimi","year":"2023","journal-title":"Circulation"},{"key":"B40","doi-asserted-by":"publisher","first-page":"2261","DOI":"10.1053\/j.jvca.2023.07.041","article-title":"Pulmonary vasodilator and inodilator drugs in cardiac surgery: a systematic review with Bayesian network meta-analysis","volume":"37","author":"Sardo","year":"2023","journal-title":"J Cardiothorac Vasc Anesth"},{"key":"B41","doi-asserted-by":"publisher","first-page":"1114","DOI":"10.1164\/rccm.201104-0662CI","article-title":"Intensive care unit management of patients with severe pulmonary hypertension and right heart failure","volume":"184","author":"Hoeper","year":"2011","journal-title":"Am J Respir Crit Care Med"},{"key":"B42","doi-asserted-by":"publisher","first-page":"811","DOI":"10.1513\/AnnalsATS.201312-446FR","article-title":"Management of acute right ventricular failure in the intensive care unit","volume":"11","author":"Ventetuolo","year":"2014","journal-title":"Ann Am Thorac Soc"},{"key":"B43","doi-asserted-by":"publisher","first-page":"1435","DOI":"10.1016\/j.jacc.2010.05.046","article-title":"Medical and surgical treatment of acute right ventricular failure","volume":"56","author":"Lahm","year":"2010","journal-title":"J Am Coll Cardiol"},{"key":"B44","doi-asserted-by":"publisher","first-page":"226","DOI":"10.1002\/ejhf.478","article-title":"Contemporary management of acute right ventricular failure: a statement from the heart failure association and the working group on pulmonary circulation and right ventricular function of the European Society of Cardiology","volume":"18","author":"Harjola","year":"2016","journal-title":"Eur J Heart Fail"},{"key":"B45","doi-asserted-by":"publisher","first-page":"774","DOI":"10.1007\/s00134-018-5172-2","article-title":"Diagnostic workup, etiologies and management of acute right ventricle failure: a state-of-the-art paper","volume":"44","author":"Vieillard-Baron","year":"2018","journal-title":"Intensive Care Med"},{"key":"B46","doi-asserted-by":"publisher","first-page":"304","DOI":"10.1093\/ehjacc\/zuad157","article-title":"Diagnosis and treatment of right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale): a clinical consensus statement","volume":"13","author":"Arrigo","year":"2024","journal-title":"Eur Heart J Acute Cardiovasc Care"},{"key":"B47","doi-asserted-by":"publisher","first-page":"1801906","DOI":"10.1183\/13993003.01906-2018","article-title":"Intensive care, right ventricular support and lung transplantation in patients with pulmonary hypertension","volume":"53","author":"Hoeper","year":"2019","journal-title":"Eur Respir J"},{"key":"B48","doi-asserted-by":"publisher","first-page":"425","DOI":"10.1016\/j.ccm.2022.04.005","article-title":"Management of the critically ill patient with pulmonary arterial hypertension and right heart failure","volume":"43","author":"Granton","year":"2022","journal-title":"Clin Chest Med"},{"key":"B49","doi-asserted-by":"publisher","first-page":"121","DOI":"10.1016\/j.ccc.2023.05.003","article-title":"Diagnosis and management of pulmonary hypertension and right ventricular failure in the cardiovascular intensive care unit","volume":"40","author":"Vaidya","year":"2024","journal-title":"Crit Care Clin"},{"key":"B50","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1016\/j.ijcard.2018.08.081","article-title":"Decompensated right heart failure, intensive care and perioperative management in patients with pulmonary hypertension: updated recommendations from the Cologne consensus conference 2018","author":"Olsson","year":"2018","journal-title":"Int J Cardiol"},{"key":"B51","doi-asserted-by":"publisher","first-page":"432","DOI":"10.3390\/jcm9020432","article-title":"The right ventricle\u2014you may forget it, but it will not forget you","volume":"9","author":"Wanner","year":"2020","journal-title":"J Clin Med"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1972194\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T11:41:22Z","timestamp":1790595682000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1972194\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,28]]},"references-count":51,"alternative-id":["10.3389\/fmed.2026.1972194"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2026.1972194","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,28]]},"article-number":"1972194"}}