Anesthesia and Adult Congenital Heart Disease

Intraoperative Hemodynamic Instability in a Patient With Ebstein's Anomaly Complicated With Eisenmenger Syndrome

Ebstein's anomaly is a rare congenital displacement of the tricuspid valve resulting in atrialization of the right ventricle. About half of the patients with Ebstein's anomaly also have atrial septal defects, which may lead to chronic shunting and development of Eisenmenger syndrome. We describe a case of a sexagenarian male patient with a history of Ebstein's anomaly complicated with Eisenmenger syndrome undergoing robotic laparoscopic adrenalectomy who presented hemodynamic instability, hypoxemia, and likely right-to-left shunting intraoperatively, as well as the actions taken to correct it and have a successful outcome. Perioperative management of adult patients with congenital heart defects is complex and requires careful monitoring. When available, intraoperative transesophageal echocardiography is strongly recommended. To prevent right-to-left shunting, maintaining elevated systemic vascular resistance with the use of vasopressors and low positive end-expiratory pressure (PEEP) ventilation is critical.

Anesthesia in adults with congenital heart disease

PURPOSE OF REVIEW

The current review focuses on patients with congenital heart disease (CHD) with regard to recent trends in global demographics, healthcare provision for noncardiac surgery, as well as anesthetic and perioperative care for these patients.

RECENT FINDINGS

About 40 years after milestones of surgical innovation in CHD, the number of adults with CHD (ACHD) now surpasses those of children with CHD. This development leads to the fact that even patients with complex CHD managed for noncardiac surgery are not restricted to highly specialized centers. However, preoperative risk assessment for anesthesia in these patients is complex due to underlying cardiac morbidity and substantial CHD-associated noncardiac morbidity. In addition to clinical assessment and echocardiography, biomarker measurement may be a clinically useful tool to estimate severity of heart failure in CHD patients. The high negative predictive value of NT-proBNP makes it particularly valuable as a screening tool. Further, morbidity and mortality in ACHD patients are mainly caused by arrhythmias and therefore are also relevant for perioperative management. Adverse events and perioperative death in ACHD patients in cardiac and noncardiac surgery are frequently related to intraoperative anesthetic care.

SUMMARY

Medical progress in treatment of CHD has shifted morbidity and mortality of these patients largely to adulthood. Future investigations including risk stratification of ACHD patients are necessary to further improve perioperative management, especially for low-risk and high-risk noncardiac management.

[Intensive care management of critically ill adults with congenital heart disease]

Due to improvements in cardiac surgery and perioperative care the number of adults with congenital heart disease is continuously growing. The perioperative and intensive care management of these patients is a challenge due to the variety of pathologies and surgical options as well as the complex pathophysiology. Many patients develop organ dysfunction with time and many require multiple cardiac operations as well as non-cardiac interventions during adulthood. While these patients are best treated in dedicated tertiary centers that provide a multidisciplinary expertise, basic knowledge of this population is important for everyone involved in acute medical care. This review will discuss some general aspects of adults with congenital heart disease such as pulmonary hypertension, Eisenmenger syndrome, cyanosis, pregnancy and perioperative care, with a special focus on the management of critically ill patients.

Anaesthetic management of hip arthroplasty in an individual with trisomy 21 and Eisenmenger's syndrome

A 49-year-old man with trisomy 21 and Eisenmenger's syndrome presented for hip arthroplasty. Eisenmenger's syndrome is defined by the presence of obstructive pulmonary vascular disease secondary to long-standing left-to-right shunt causing pulmonary hypertension, eventually leading to shunt reversal in to right-to-left direction. Patients with Eisenmenger's syndrome pose a significant perioperative risk because of the physiological alterations induced by anaesthetic agents. The choice of anaesthetic technique in these patients is therefore not straightforward. A successful outcome was achieved with general anaesthesia supplemented with nerve blocks.

Adult congenital heart disease

For a decade now, it has been recognized that optimal management of adult congenital heart disease (ACHD) requires a skilled multidisciplinary team. The size and complexity of the population of adults with congenital heart disease (CHD) are increasing. This article reviews the general considerations for giving an anesthetic to an adult with CHD for cardiac or noncardiac surgery and provides further elaboration for a variety of complex patient types. Lastly, the advantages of an organized multidisciplinary approach to patients with ACHD are discussed.

The diagnostic process and perioperative and anesthetic management of an undiagnosed congenital cyanotic cardiac defect in an adult for trauma surgery

A 39-year-old patient awaiting emergency surgery due to a crush foot injury, with an undiagnosed cyanotic cardiac lesion that was diagnosed later as a complete atrioventricular canal defect, is presented. Complete atrioventricular canal defects usually present in the first few months of life and can be fatal if not treated in the first few years. Adult patients with congenital cardiac malformations seem to be at increased risk for noncardiac surgery. The diagnostic process, perioperative management, and anesthetic implications are discussed.

Anaesthesia and right ventricular failure

Acute right ventricular (RV) failure has until recently received relatively little attention in the cardiology, critical care or anaesthesia literature. However, it is frequently encountered in cardiac surgical cases and is a significant cause of mortality in patients with severe pulmonary hypertension who undergo non-cardiac surgery. RV dysfunction may be primarily due to impaired RV contractility, or volume or pressure overload. In these patients, an increased pulmonary vascular resistance (PVR) or a decreased aortic root pressure may lead to RV ischaemia, resulting in a rapid, downward haemodynamic spiral. The key aspects of 'RV protection' in patients who are at risk of perioperative decompensation are prevention, detection and treatment aimed at reversing the underlying pathophysiology. Minimising PVR and maintaining systemic blood pressure are of central importance in the prevention of RV decompensation, which is characterised by a rising central venous pressure and a falling cardiac output. Although there are no outcome data to support any therapeutic strategy for RV failure when PVR is elevated, the combination of inhaled iloprost or intravenous milrinone with oral sildenafil produces a synergistic reduction in PVR, while sparing systemic vascular resistance. Levosimendan is a promising new inotrope for the treatment of RV failure, although its role in comparison to older agents such as dobutamine, adrenaline and milrinone has yet to be determined. This is also the case for the use of vasopressin as an alternative pressor to noradrenaline. If all else has failed, mechanical support of the RV should be considered in selected cases.

Relief of Fontan obstruction demonstrated non-invasively by cardiac magnetic resonance imaging

Greater numbers of children with congenital heart disease are surviving to adulthood. The non-invasive assessment and surveillance of these patients, still based primarily on transthoracic echocardiography, has been significantly enhanced by the advent, and more widespread use of, cardiac magnetic resonance imaging. We report on the influence of cardiac magnetic resonance imaging in the initial evaluation of, and response to treatment in, a patient who had developed an obstruction within her Fontan circuit.

Children with cardiomyopathy: complications after noncardiac procedures with general anesthesia

BACKGROUND

Children with cardiomyopathy (CM) often undergo procedures that require general anesthesia (GA) but little is known about anesthesia-related adverse events or postprocedural outcomes.

METHODS

After approval, all children with CM who underwent nonopen heart surgical procedures and/or diagnostic imaging under GA at a tertiary children's hospital during January 2002 to May 2005 were identified from a clinical database. Based on their preprocedure fractional shortening (FS) on echocardiogram, systemic ventricular dysfunction was categorized as mild (FS 23-28%), moderate (FS 16-22%), or severe (FS < 16%) and those with normal (FS > 28%) were excluded from review.

RESULTS

Twenty-six patients underwent 34 procedures under GA, of whom 13 (38%) had mild or moderate ventricular dysfunction and 21 (62%) had severe dysfunction. Common procedures included pacer/defibrillator placement (43%) and imaging studies (18%). Eighteen complications were noted in 12 patients. Fifteen (83%) complications occurred in patients with severe ventricular dysfunction. One patient with severe ventricular dysfunction died (3% mortality). Hypotension requiring inotropic support was the most frequent complication (61%). Children with severe ventricular dysfunction often required hospital support pre- and postprocedure with 67% requiring intensive care. Hospital stay was longer for patients with severe ventricular dysfunction compared with children with mild or moderate ventricular dysfunction (P = 0.006).

CONCLUSIONS

The 30-day mortality rate was low but complications were common, especially in patients with severe ventricular dysfunction. For these patients, we recommend early consideration of perioperative intensive care support to optimize cardiovascular therapy and monitoring.