The case The patient is a 43-year-old female who has had a history of idiopathic pulmonary hypertension for many years. Her home treatment regimen consisted of numerous medications, including a continuous IV infusion of Flolan delivered by a patient-controlled pump. A recent echocardiogram revealed a RVSP (right ventricular systolic pressure) of 127 mmHg, and right heart catheterization was significant for pulmonary artery pressures greater than her systemic blood pressures. A decline in her functional status over the past 2 weeks landed her a top spot on the lung transplant list and a “luxurious” room on Osler 4. She is the youngest of many children and is surrounded by her entire family awaiting the news: will these lungs be good enough? She has been in this position before, anxiously anticipating her new set of lungs. She has been disappointed once before and remembers the words “I'm sorry, but it's a no-go” all too clearly. You thoroughly discuss the anesthetic plan with the patient and her family. They are quite intelligent and ask some pretty in-depth questions. You breathe a sigh of relief as you answer the final question. You explain that you will take excellent care of the patient as you try to put them at ease. They smile, and you feel as if you gained their trust. However, now that their fears have been allayed, you can't help but feel anxious yourself about the monumental task you have ahead: the responsibility of getting her safely through the operation.