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Anesthetic considerations for Fontan circulation and pregnancy. Int Anesthesiol Clin 2021; 59:52-59. [PMID: 34029248 DOI: 10.1097/aia.0000000000000329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Salik I, Awad M, Barst S. Anesthetic management of small bowel obstruction in a pediatric patient with heterotaxy syndrome and Fontan physiology. J Clin Anesth 2019; 56:1-2. [PMID: 30660812 DOI: 10.1016/j.jclinane.2019.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 12/14/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Irim Salik
- Department of Pediatric Anesthesiology at Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America.
| | - Motaz Awad
- Department of Pediatric Anesthesiology at Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America
| | - Samuel Barst
- Department of Pediatric Anesthesiology at Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America
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Abstract
Parturient with corrected or uncorrected cardiac problem may undergo neuraxial anaesthesia for several reasons and in different trimesters. The altered physiological state in a parturient is further deranged in the presence of a cardiovascular lesion, producing the added risk to the parturient undergoing a neuraxial block. A detailed evaluation, knowledge regarding cardiovascular disease state, more vigilant monitoring, and a team approach can lead to a successful outcome.
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Affiliation(s)
- Minati Choudhury
- Department of Cardiac Anaesthesia Cardiothoracic Sciences Centre, AIIMS, New Delhi, India
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Abstract
Management of pregnant women with heart disease remains challenging due to the advancement of innovations in cardiac surgery and correction of complex cardiac anomalies, and more recently, with the successful performance of heart transplants, cardiac diseases are not only likely to coexist with pregnancy, but will also increase in frequency over the years to come. In developing countries with a higher prevalence of rheumatic fever, cardiac disease may complicate as many as 5.9% of pregnancies with a high incidence of maternal death. Since many of these deaths occur during or immediately following parturition, heart disease is of special importance to the anesthesiologist. This importance arises from the fact that drugs used for preventing or relieving pain during labor and delivery exert a major influence - for better or for worse - on the prognosis of the mother and newborn. Properly administered anesthesia and analgesia can contribute to the reduction of maternal and neonatal mortality and morbidity.
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Affiliation(s)
- Ankur Luthra
- Department of Anaesthesia and Intensive Care, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritika Bajaj
- Department of Obstetrics and Gynaecology, Jindal IVF and Sant Memorial Nursing Home, Sector 20, Chandigarh, India
| | - Anudeep Jafra
- Department of Anaesthesia and Intensive Care, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - VK Arya
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Successful epidural anesthesia for cesarean delivery in a woman with Fontan repair. J Clin Anesth 2015; 27:60-2. [DOI: 10.1016/j.jclinane.2014.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/15/2014] [Accepted: 08/22/2014] [Indexed: 11/24/2022]
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Tiouririne M, de Souza DG, Beers KT, Yemen TA. Anesthetic Management of Parturients With a Fontan Circulation. Semin Cardiothorac Vasc Anesth 2015; 19:203-9. [DOI: 10.1177/1089253214566887] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Parturients with Fontan physiology provide unique and complex challenges to anesthesiologists. Such challenges include the maintenance of a perfect balance between preload, pulmonary vascular resistance, afterload, and cardiac output in a setting of a single ventricle physiology. The physiological changes of pregnancy add additional burden to an already “fragile” physiology, making the anesthetic management for labor and/or cesarean delivery even more complex. Understanding the impact of these changes on the Fontan physiology and the effect of anesthetic choices on this dyad (pregnancy–Fontan) is an imperative prior to caring for these patients. In an effort to determine how these patients are best managed for labor and/or cesarean delivery, we have reviewed the literature examining the peripartum anesthetic management of parturients with Fontan circulation and have identified 27 case reports.
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Gribaa R, Slim M, Ouali S, Neffati E, Remadi F, Boughzela E. Four successful pregnancies in a woman after Fontan palliation: a case report. J Med Case Rep 2014; 8:350. [PMID: 25335555 PMCID: PMC4209458 DOI: 10.1186/1752-1947-8-350] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 08/18/2014] [Indexed: 11/30/2022] Open
Abstract
Introduction A Fontan operation is performed to provide palliation for patients with many forms of highly complex congenital heart disease that cannot support a biventricular circulation. Increasing numbers of women who have undergone these connections in childhood are now reaching their childbearing years, and some are becoming pregnant. The low flow and fixed cardiac output of a Fontan circulation poses several problems during pregnancy. Case presentation We report the case of four successful pregnancies in a 31-year-old Tunisian woman with congenital tricuspid atresia after Fontan operation. Her pregnancies resulted in delivery of four healthy neonates. Her clinical status remained unchanged. Conclusions This case suggests that patients after adequate Fontan palliation could complete pregnancy without long-term cardiac sequelae. Intensive care should be provided with specialists, including a neonatologist, anesthesiologist and cardiologist.
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Affiliation(s)
| | - Mehdi Slim
- Department of Cardiology, Sahloul University Hospital, Sousse, Tunisia.
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Le Gloan L, Mercier LA, Dore A, Marcotte F, Mongeon FP, Ibrahim R, Asgar A, Poirier N, Khairy P. Pregnancy in women with Fontan physiology. Expert Rev Cardiovasc Ther 2014; 9:1547-56. [DOI: 10.1586/erc.11.158] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Grim KJ, Arendt KW, Jacob AK, Rose CH, Keegan MT. Urgent cesarean delivery and prolonged ventilatory support in a parturient with Fontan circulation and undiagnosed pseudocholinesterase deficiency. Int J Obstet Anesth 2011; 20:184-8. [PMID: 21388803 DOI: 10.1016/j.ijoa.2010.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 11/18/2010] [Accepted: 11/22/2010] [Indexed: 01/19/2023]
Abstract
A parturient with Fontan circulation required general anesthesia for urgent cesarean delivery and subsequent prolonged postoperative ventilation for newly-diagnosed pseudocholinesterase deficiency. Anesthetic management necessitated a thorough understanding of the hemodynamic principles of the Fontan circulation and physiologic adaptations during surgical delivery and recovery in the intensive care unit.
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Affiliation(s)
- K J Grim
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA
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Eagle SS, Daves SM. The Adult With Fontan Physiology: Systematic Approach to Perioperative Management for Noncardiac Surgery. J Cardiothorac Vasc Anesth 2011; 25:320-34. [DOI: 10.1053/j.jvca.2010.12.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Indexed: 01/19/2023]
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[Management of cardiac high risk pregnancy. Caesarean section in a primagravida with cyanotic cardiac defect]. Anaesthesist 2010; 60:57-62. [PMID: 20552151 DOI: 10.1007/s00101-010-1741-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A 37-year-old gravida I with cyanotic heart disease presented for caesarean section in the 31st week of gestation. Caesarean section was performed uneventfully with the patient under epidural anaesthesia accompanied by invasive monitoring. Postoperative echocardiography showed no change in the shunt fraction, volumes or the ventricular function. Every patient with complex comorbidities has to be managed according to individual prerequisites and the experiences and preferences of the team. For such high risk pregnancies regional anaesthesia seems to be a possible option although no clear evidence can be found in the literature.
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Drenthen W, Pieper PG, Roos-Hesselink JW, van Lottum WA, Voors AA, Mulder BJM, van Dijk APJ, Vliegen HW, Yap SC, Moons P, Ebels T, van Veldhuisen DJ. Outcome of pregnancy in women with congenital heart disease: a literature review. J Am Coll Cardiol 2007; 49:2303-11. [PMID: 17572244 DOI: 10.1016/j.jacc.2007.03.027] [Citation(s) in RCA: 349] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 02/27/2007] [Accepted: 03/13/2007] [Indexed: 01/18/2023]
Abstract
A search of peer-reviewed literature was conducted to identify reports that provide data on complications associated with pregnancy in women with structural congenital heart disease (CHD). This review describes the outcome of 2,491 pregnancies, including 377 miscarriages (15%) and 114 elective abortions (5%). Important cardiac complications were seen in 11% of the pregnancies. Obstetric complications do not appear to be more prevalent. In complex CHD, premature delivery rates are high, and more children are small for gestational age. The offspring mortality was high throughout the spectrum and was related to the relatively high rate of premature delivery and recurrence of CHD.
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Affiliation(s)
- Willem Drenthen
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands.
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Ioscovich A, Briskin A, Fadeev A, Grisaru-Granovsky S, Halpern S. Emergency cesarean section in a patient with Fontan circulation using an indwelling epidural catheter. J Clin Anesth 2006; 18:631-4. [PMID: 17175437 DOI: 10.1016/j.jclinane.2006.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Revised: 05/06/2006] [Accepted: 05/08/2006] [Indexed: 10/23/2022]
Abstract
Management of parturients with a history of Fontan procedure requires careful monitoring of cardiovascular parameters and anticipation of potential complications. We describe potential pitfalls in a parturient with atriopulmonary Fontan circulation, who received epidural analgesia for labor and who later required emergency cesarean section. Low-dose local anesthetic in combination with meperidine provided excellent perioperative epidural analgesia and cardiovascular stability. Epidural analgesia during labor offered optimal pain relief and facilitated conversion to surgical anesthesia for an emergency cesarean section.
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MESH Headings
- Adult
- Analgesia, Epidural/instrumentation
- Analgesia, Epidural/methods
- Analgesics, Opioid/administration & dosage
- Anesthesia, Epidural/instrumentation
- Anesthesia, Epidural/methods
- Anesthesia, Obstetrical/instrumentation
- Anesthesia, Obstetrical/methods
- Catheters, Indwelling
- Cesarean Section/methods
- Emergency Treatment/methods
- Female
- Fontan Procedure
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/surgery
- Humans
- Meperidine/administration & dosage
- Pregnancy
- Pregnancy Complications, Cardiovascular
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Affiliation(s)
- A Ioscovich
- Department of Anesthesia, Shaare Zedek Medical Center, Jerusalem, Israel.
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Affiliation(s)
- Pierre-Guy Chassot
- Department of Anaesthesiology, University Hospital of Lausanne, Lausanne, Switzerland.
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Drenthen W, Pieper PG, Roos-Hesselink JW, van Lottum WA, Voors AA, Mulder BJM, van Dijk APJ, Vliegen HW, Sollie KM, Moons P, Ebels T, van Veldhuisen DJ. Pregnancy and delivery in women after Fontan palliation. Heart 2006; 92:1290-4. [PMID: 16449503 PMCID: PMC1861147 DOI: 10.1136/hrt.2005.085407] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To evaluate the outcome of pregnancy in women after Fontan palliation and to assess the occurrence of infertility and menstrual cycle disorders. DESIGN AND PATIENTS Two congenital heart disease registries were used to investigate 38 female patients who had undergone Fontan palliation (aged 18-45 years): atriopulmonary anastomosis (n = 23), atrioventricular connection (n = 5) and total cavopulmonary connection (n = 10). RESULTS Six women had 10 pregnancies, including five miscarriages (50%) and one aborted ectopic pregnancy. During the remaining four live-birth pregnancies clinically significant complications were encountered: New York Heart Association class deterioration; atrial fibrillation; gestational hypertension; premature rupture of membranes; premature delivery; fetal growth retardation and neonatal death. Four of seven women who had attempted to become pregnant reported female infertility: non-specified secondary infertility (n = 2), uterus bicornis (n = 1) and related to endometriosis (n = 1). Moreover, several important menstrual cycle disorders were documented. In particular, the incidence of primary amenorrhoea was high (n = 15, 40%), which resulted in a significant increase in age at menarche (14.6 (SD 2.1) years, p < 0.0001, compared with the general population). CONCLUSION Women can successfully complete pregnancy after adequate Fontan palliation without important long-term sequelae, although it is often complicated by clinically significant (non-)cardiac events. In addition, subfertility or infertility and menstrual disorders were common.
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Affiliation(s)
- W Drenthen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
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Eid L, Ginosar Y, Elchalal U, Pollak A, Weiniger CF. Caesarean section following the Fontan procedure: two different deliveries and different anaesthetic choices in the same patient. Anaesthesia 2005; 60:1137-40. [PMID: 16229700 DOI: 10.1111/j.1365-2044.2005.04334.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The Fontan procedure is performed for patients with a hypoplastic right ventricle, and pregnancies following this palliative surgery are likely to increase. We present a parturient with the Fontan physiology who successfully underwent two consecutive caesarean deliveries; the first under general anaesthesia for emergency surgery and the second under regional anaesthesia for elective surgery. We suggest that pregnancy and delivery do not typically adversely affect maternal cardiac status in these patients. Attention must be paid, however, to fetal loss, prematurity, growth retardation and associated cardiac congenital malformations for which insufficient data exist in the literature in this patient population.
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Affiliation(s)
- L Eid
- Resident, Department of Anaesthesiology and Critical Care, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem, Israel
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Vischoff D, Fortier LP, Villeneuve E, Boutin C, Labelle H. Anaesthetic management of an adolescent for scoliosis surgery with a Fontan circulation. Paediatr Anaesth 2002; 11:607-10. [PMID: 11696127 DOI: 10.1046/j.1460-9592.2001.00715.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Advances in the treatment of congenital heart disease have led to a new group of adolescents or adults patients with cardiac anomalies. The anaesthetic management of these patients can be challenging especially when they are scheduled for major noncardiac surgery inducing haemodynamic instability. We report the case of a 14-year-old boy scheduled for posterior spinal fusion for idiopathic scoliosis who underwent a Fontan operation in infancy for pulmonary atresia with right ventricle hypoplasia. The preoperative investigations and the anaesthetic management are described.
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Affiliation(s)
- D Vischoff
- Department of Anaesthesiology, Ste-Justine Hospital and University of Montreal, Montreal, Canada.
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Abstract
We describe four successful pregnancies in three women who had previously had a Fontan repair for congenital heart disease. Each pregnancy resulted in a live birth and there was no maternal mortality The infants were premature, being delivered at 26, 30 and 35 weeks, and weighing 1,020, 1,333 and 1,930 g respectively The fourth infant was born at 32 weeks and no birthweight is available. Maternal complications occurred and were those anticipated after a Fontan repair. Two mothers required treatment for supraventricular arrhythmias (atrial flutter and fibrillation). Ventricular failure was present in two mothers and required ongoing drug treatment. Raised systemic venous pressures caused peripheral oedema in two mothers and hepatomegaly and ascites in one mother. The physiology, potential complications, anaesthetic concerns and drug treatment in pregnancy after Fontan repair are discussed.
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Affiliation(s)
- J V Hoare
- Prince Charles Hospital, Brisbane, Queensland, Australia
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Buckland R, Pickett JA. Pregnancy and the univentricular heart: case report and literature review. Int J Obstet Anesth 2000; 9:55-63. [PMID: 15321109 DOI: 10.1054/ijoa.1999.0341] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The univentricular heart is a rare form of congenital cardiac disease. We report the successful management of a parturient with a single ventricle, transposition of the great arteries, pulmonary hypertension and thrombosis of the superior vena cava. The univentricular heart is discussed in detail and the outcome in other mothers with similar cardiac anomalies is reviewed.
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Affiliation(s)
- R Buckland
- Department of Anaesthesia, Addenbrooke's NHS Trust, Cambridge, UK
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Anesthetic management of pediatric patients following fontan operation. J Anesth 1997; 11:65-67. [DOI: 10.1007/bf02480006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/1996] [Accepted: 06/17/1996] [Indexed: 10/24/2022]
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Jonmarker C. Patients with congenital heart malformations for noncardiac surgery. ACTA ANAESTHESIOLOGICA SCANDINAVICA. SUPPLEMENTUM 1997; 110:104-5. [PMID: 9248552 DOI: 10.1111/j.1399-6576.1997.tb05520.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Most patients with CHD can be safely anesthetized with regular techniques. Preoperative consultation with appropriate specialists and a well planned anesthetic management is important.
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Affiliation(s)
- C Jonmarker
- Department of Anesthesia and Intensive Care, Lund University Hospital, Sweden
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Abstract
OBJECTIVES This study sought to determine risks and outcome of pregnancy and delivery after the modified Fontan operation. BACKGROUND Increasingly, female Fontan patients reaching child-bearing years are interested in having children. To date, the number of reported pregnancies is small, and pregnancy has therefore been discouraged. METHODS One hundred ten of 126 female patients from the Fontan registries of the Mayo Clinic and University of California Los Angeles Medical Center responded to a mailed questionnaire. An additional six patients with a reported pregnancy from other centers were identified and reviewed to assess pregnancy outcomes. RESULTS Among the participating centers, a total of 33 pregnancies after Fontan operation for various types of univentricular heart disease were reported. There were 15 (45%) live births from 14 mothers, with 13 spontaneous abortions and 5 elective terminations. In the 14 women with live births, the median number of years between operation and pregnancy was 4 (range 2 to 14). Reported prepregnancy problems in these gravidas included atrial flutter in one patient and ventricular dysfunction, aortic regurgitation and atrioventricular valve regurgitation in another. One patient developed supraventricular tachycardia during pregnancy and had conversion to sinus rhythm. No maternal cardiac complications were reported during labor, delivery or the immediate puerperium. There were six female and nine male infants (mean gestational age 36.5 weeks; median weight 2,344 g). One infant had an atrial septal defect. At follow-up, mothers and infants were alive and well. CONCLUSIONS Pregnancy after the Fontan operation appears to have been well tolerated in 13 to 14 gravidas. There does appear to be an increased risk of miscarriage. The tendency to routinely discourage pregnancy may need to be reconsidered.
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Affiliation(s)
- M M Canobbio
- University of California Los Angeles School of Nursing 90095-1702, USA
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Abstract
In adults with congenital heart disease who are confronted with noncardiac surgery, perioperative risks can be reduced, often appreciably, when problems inherent to this patient population are anticipated. The first necessity is to clarify the diagnosis and to be certain that appropriate information is obtained from a cardiologist with adequate knowledge of congenital heart disease in adults. Physiology and anatomy can vary significantly among patients who superficially carry identical diagnoses. Elective noncardiac surgery should be preceded by clinical assessment including review of clinical and laboratory data and securing the results of necessary diagnostic studies. Preoperative assessment should be performed far enough in advance of the anticipated date of surgery to allow critical assessment of the data and potential discussions with colleagues. Appropriate cardiovascular laboratory studies to be obtained or reviewed include electrocardiograms, chest radiographs, echocardiograms, and cardiac catheterization data, which may include specialized intracardiac electrophysiologic testing. Congenital heart disease in adults is a new and evolving area of special interest and expertise in cardiovascular medicine. Multidisciplinary centers for the care of these patients are being developed. The 22nd Bethesda Conference recommended that these centers include among their consultants anesthesiologists with special expertise in managing patients with congenital heart disease. These anesthesiologists can have the option of serving either as the attending anesthesiologists when patients require noncardiac surgery or as consultants and resource individuals to other anesthesiologists.
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Affiliation(s)
- V C Baum
- Department of Anesthesiology, University of Virginia, Charlottesville 22908, USA
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