Defined as RVH (and subsequent ventricular dysfunction) secondary to chronic pulmonary hypertension. The key to management in these patients is to avoid increasing PVR (precipitants include hypoxemia, hypercarbia, acidosis, nitrous oxide [Hilgenberg JC et al. Anesth Analg 59: 323, 1980]). In severe cases, beta-agonists may be required to overcome PVH, but with the concomitant risk of myocardial ischemia. Phosphodiesterase inhibitors (amrinone, milrinone) may be needed as they can both improve ventricular function and induce vasodilation (thus reducing afterload).