Laparoscopic cholecystectomy in a patient with Fontan circulation

BACKGROUND

Fontan circulation is created when a baby is born with only one functioning cardiac ventricle. A series of surgeries are performed to allow the ventricle to provide oxygenated blood to the systemic circulation and to create passive flow of venous blood to the pulmonary circulation via a conduit. Laparoscopic surgery poses several hemodynamic challenges to a patient with Fontan physiology attributable to carbon dioxide insufflation, positive pressure ventilation, and reverse Trendelenburg positioning.

CLINICAL FEATURES

A 39-yr-old male with a Fontan physiology was referred to our tertiary care centre because of repeated bouts of cholecystitis requiring a percutaneous drain and now elective laparoscopic cholecystectomy. Because of repeated cardiac surgeries, the patient also had complete heart block and was pacemaker dependent. We placed an arterial catheter prior to induction of general anesthesia with tracheal intubation. Transesophageal echocardiography allowed for real-time intraoperative assessment of venous blood flow through the patient's extracardiac diversion system throughout the surgery. This information was used to guide management and determine circulation tolerance during the various stages of laparoscopy. Inhaled milrinone resulted in the shunt fraction returning to the patient's baseline. Intraperitoneal pressure was kept below 10 mm Hg, and systemic blood pressure was supported with a low-dose norepinephrine infusion.

CONCLUSIONS

Intraoperative transesophageal echocardiography is a useful monitoring device during laparoscopic surgery when a patient has Fontan circulation. Knowing how to administer inhaled milrinone is a useful skill to decrease the shunt fraction through a patient's conduit, increasing pulmonary blood flow while avoiding hypotension.

Deep Sedation in Pediatric Patients With Single Ventricle Physiology Outside of the Operating Room

Background: Advancements in palliative surgery of patients with single ventricle physiology have led to an increase in the need for deep sedation protocols for painful procedures. However, positive pressure ventilation during anesthesia can result in unfavorable cardiopulmonary interactions. This patient population may benefit from sedation from these painful procedures. Methods: This study aims to demonstrate the safety and efficacy of deep sedation by pediatric intensivists outside the operating room for children with single ventricle physiology. This is a single-center, retrospective chart review on consecutive pediatric patients with single ventricle physiology who received deep sedation performed by pediatric intensivists between 2013 and 2020. Results: Thirty-three sedations were performed on 27 unique patients. The median age was 3.7 years (25th%-75th%: 2.1-15.6). The majority of the sedations, 88% (29/33), were done on children with Fontan physiology and 12% (4/33) were status-post superior cavopulmonary anastomosis. The primary cardiac defect was hypoplastic left heart in 63% (17/27) of all sedation procedures. There were 24 chest tube placements and 9 cardioversions. Ketamine alone [median dose 1.5 mg/kg (range 0.8-3.7)], ketamine [median dose 1 mg/kg (range 0.1-2.1)] with propofol [median dose 2.3 mg/kg (range 0.7-3.8)], and ketamine [median dose 1.5 mg/kg (range 0.4-3.0)] with morphine [median dose 0.06 mg/kg (range 0.03-0.20)] were the most common sedation regimens used. Adverse events (AEs) occurred in 4 patients (15%), three of which were transient AEs. All sedation encounters were successfully completed. Conclusion: Procedural deep sedation can be safely and effectively administered to single ventricle patients by intensivist-led sedation teams in selective case.

Anaesthetic management of a child with Fontan heart undergoing laparoscopic cholecystectomy: A case report

The Fontan procedure is a staged palliative surgery performed in children with congenital univentricular heart defects. These individuals are predisposed to a variety of issues due to their altered physiology. Through this article, we would like to describe the evaluation and anaesthetic management of a 14-year-old boy with Fontan circulation who underwent an uneventful laparoscopic cholecystectomy. The key to successful management was a multidisciplinary approach throughout the perioperative period as these patients pose a unique set of problems.

In Silico Evaluation of a Self-powered Venous Ejector Pump for Fontan Patients

PURPOSE

The Fontan circulation carries a dismal prognosis in the long term due to its peculiar physiology and lack of a subpulmonic ventricle. Although it is multifactorial, elevated IVC pressure is accepted to be the primary cause of Fontan's high mortality and morbidity. This study presents a self-powered venous ejector pump (VEP) that can be used to lower the high IVC venous pressure in single-ventricle patients.

METHODS

A self-powered venous assist device that exploits the high-energy aortic flow to lower IVC pressure is designed. The proposed design is clinically feasible, simple in structure, and is powered intracorporeally. The device's performance in reducing IVC pressure is assessed by conducting comprehensive computational fluid dynamics simulations in idealized total cavopulmonary connections with different offsets. The device was finally applied to complex 3D reconstructed patient-specific TCPC models to validate its performance.

RESULTS

The assist device provided a significant IVC pressure drop of more than 3.2 mm Hg in both idealized and patient-specific geometries, while maintaining a high systemic oxygen saturation of more than 90%. The simulations revealed no significant caval pressure rise (< 0.1 mm Hg) and sufficient systemic oxygen saturation (> 84%) in the event of device failure, demonstrating its fail-safe feature.

CONCLUSIONS

A self-powered venous assist with promising in silico performance in improving Fontan hemodynamics is proposed. Due to its passive nature, the device has the potential to provide palliation for the growing population of patients with failing Fontan.

Heart Failure in Complex Congenital Heart Disease of the Adult

PURPOSE OF REVIEW

Adult congenital heart disease (ACHD) patients have demonstrated improved survival, especially those with severely complex disease, mainly single-ventricle/Fontan physiology and those with a systemic right ventricle. We describe the heart failure phenotypes of complex CHD, reversible causes for heart failure, and considerations for advanced therapy.

RECENT FINDINGS

While initially marketed for application to patients with acquired causes for heart failure, newer devices and technologies have started to be used in the ACHD population. After reversible causes for heart failure in CHD are addressed, it is reasonable to consider use of new device-based technologies and orthotopic heart transplant (OHT) for end-stage disease. New heart failure technology and organ transplant should carefully be considered and applied in complex ACHD, where there may be significant improvement in morbidity and mortality.

Computational Fluid Dynamics Support for Fontan Planning in Minutes, Not Hours: The Next Step in Clinical Pre-Interventional Simulations

Computational fluid dynamics (CFD) modeling may aid in planning of invasive interventions in Fontan patients. Clinical application of current CFD techniques is however limited by complexity and long computation times. Therefore, we validated a “lean” CFD method to magnetic resonance imaging (MRI) and an “established” CFD method, ultimately aiming to reduce complexity to enable predictive CFD during ongoing interventions. Fifteen Fontan patients underwent MRI for CFD modeling. The differences between lean and established approach, in hepatic and total flow percentage to the left pulmonary artery (%LPA), power loss and relative wall shear stress area were 1.5 ± 4.0%, -0.17 ± 1.1%, -0.055 ± 0.092 mW and 1.1 ± 1.4%. Compared with MRI, the lean and established method showed a bias in %LPA of -1.9 ± 3.4% and -1.8 ± 3.1%. Computation time was for the lean and established approach 3.0 ± 2.0 min and 7.0 ± 3.4 h, respectively. We conclude that the proposed lean method provides fast and reliable results for future CFD support during interventions.

Anesthetic management for the peripartum care of women with Fontan physiology

BACKGROUND

As outcomes for surgical palliation have improved, women with single ventricle congenital heart disease are surviving into their reproductive years and may become pregnant. The cardiovascular changes of pregnancy may stress the Fontan circulation and pose significant risk to the mother and fetus.

METHODS

Pregnant women with Fontan physiology were identified from the Ahmanson/UCLA Adult Congenital Heart Disease Center database. A total of 37 pregnancies were identified between 2000 and 2019. Twenty live births from 19 patients were reviewed and compared for cardiac history, obstetric history, anesthetic management and cardiovascular outcomes.

RESULTS

Median gestational age at delivery was 35 weeks. Ten of 20 births were by cesarean delivery. An epidural technique was used as the primary anesthetic for 19 deliveries and general anesthesia was used for one cesarean delivery. An arterial line was placed in the peripartum period for three deliveries. Central venous access was established in the peripartum period for one patient. The mean blood loss for cesarean deliveries was 626 mL (range 240-1200 mL). The mean net peri-operative intake/output was positive 93.5 mL. Three patients were briefly transferred to the intensive care unit postpartum for higher level monitoring and care.

CONCLUSION

Epidural anesthesia is safe and effective for both vaginal and cesarean deliveries. Judicious fluid management is critical in minimizing postpartum cardiovascular complications. Many patients do not require a higher level of care, invasive monitoring or central venous access during the peripartum period.

Perioperative and long-term management of Fontan patients

A Fontan circulation requires a series of three-staged operations aimed to palliate patients with single-ventricle CHD. Currently, the most frequent technique is the extracardiac total cavopulmonary connection, an external conduit connecting the IVC and right pulmonary artery, bypassing the right side of the heart. Fontan candidates must meet strict criteria; they are assessed utilising both cardiac catheterisation and cardiac magnetic resonance. Postoperatively, treatment protocols prioritise antibiotic prophylaxis, diuretics, angiotensin-converting enzyme inhibitors, anticoagulation, and oxygen therapy with fluid restriction and a low-fat diet. These measures aim to reduce length of stay in the ICU and hospital by preventing acute complications such as infection, venous thromboembolism, low cardiac output, pleural effusion, and acute kidney injury. Late complications of a Fontan procedure include circulation failure, protein-losing enteropathy, plastic bronchitis, and Fontan-associated liver disease. The definitive management is cardiac transplantation, with promising innovations in selective embolisation of lymphatic vessels and Fontan-specific ventricular assist devices. Further research assessing current protocols in the perioperative management of Fontan patients would be beneficial for standardising current practice and improving outcomes.

Fontan-Associated Liver Disease: Screening, Management, and Transplant Considerations

Surgical innovation and multidisciplinary management have allowed children born with univentricular physiology congenital heart disease to survive into adulthood. An estimated global population of 70 000 patients have undergone the Fontan procedure and are alive today, most of whom are <25 years of age. Several unexpected consequences of the Fontan circulation include Fontan-associated liver disease. Surveillance biopsies have demonstrated that virtually 100% of these patients develop clinically silent fibrosis by adolescence. As they mature, there are increasing reports of combined heart-liver transplantation resulting from advanced liver disease, including bridging fibrosis, cirrhosis, and hepatocellular carcinoma, in this population. In the absence of a transplantation option, these young patients face a poor quality of life and overall survival. Acknowledging that there are no consensus guidelines for diagnosing and monitoring Fontan-associated liver disease or when to consider heart transplantation versus combined heart-liver transplantation in these patients, a multidisciplinary working group reviewed the literature surrounding Fontan-associated liver disease, with a specific focus on considerations for transplantation.

Recent Developments in Cardiology Procedures for Adult Congenital Heart Disease: The Anesthesiologist's Perspective

Many children born today with congenital heart disease can expect to live long into adulthood. Improvements in surgical technique and anesthetic and perioperative care have significantly increased the number of survivors. Unfortunately, as these patients progress through life they frequently require further interventions. Although surgical intervention may be required frequently, these patients can be managed in the cardiac catheterization or electrophysiology laboratory. Surgical correction of tetralogy of Fallot can leave patients with pulmonary valve dysfunction later in life. A percutaneous approach is now available for these patients, which can obviate the need for resternotomy. During deployment of the valve, anesthesiologists should be aware that compression of coronary arteries can occur. Adult congenital heart disease (ACHD) patients often require pacemaker/implantable cardioverter- defibrillator (ICD) insertion or ablation therapy. These patients may have altered cardiac anatomy, which can make endovascular procedures extremely challenging. Recent developments have made these procedures safer and more efficient. A number of congenital cardiac conditions can also be associated with orofacial abnormalities. ACHD patients, as a result, can present with challenging airways. The catheterization laboratory may not be the optimum environment for the anesthesiologist to manage a difficult airway. The requirement of transesophageal echocardiography for some cath eterization procedures needs to be considered when deciding on an airway management plan. Knowledge of the underlying cardiac anatomy and the planned procedure is advised when providing anesthesia for this complex patient group outside the theater setting.

Anaesthetic management of a patient with Fontan physiology for electrophysiology study and catheter ablation

The success of the Fontan procedure for congenital single ventricle anatomy has resulted in adult patients with Fontan physiology requiring anaesthesia for cardiac and non-cardiac procedures. We present the perioperative management of a patient with Fontan physiology who underwent electrophysiological study with radiofrequency ablation for atrial tachycardia under general anaesthesia. Good communication between the multidisciplinary teams, a detailed understanding of the patient's complex cardiac anatomy and physiology, as well as the ability to recognise and manage perioperative complications all play a vital role for a successful outcome.

Pregnancy in Women with Congenital Heart Disease

OPINION STATEMENT

Advances in cardiac surgical interventions in infancy and childhood have led to an increased number of women with congenital heart disease of childbearing age. For these women, individualized preconception counseling and pregnancy planning should be a vital component of their medical management, and presentation for obstetric care may even be an opportunity to re-establish cardiovascular care for patients who have been lost to follow-up. These patients have unique cardiovascular anatomy and physiology, which is dependent upon the surgical intervention they may have undergone during childhood or adolescence. These factors are associated with a variety of long-term complications, and the normal hemodynamic changes of pregnancy may unmask cardiac dysfunction and pose significant risk. Among three published risk assessment algorithms, the World Health Organization classification is the most sensitive in predicting maternal cardiovascular events in this population. Women with simple congenital heart defects generally tolerate pregnancy well and can be cared for in the community with careful monitoring. Conversely, women with complex congenital defects, with or without surgical repair and/or residual defects, should be managed in tertiary care centers under a multidisciplinary team of physicians experienced in adult congenital heart disease and high-risk obstetrics, who collaboratively participate in pregnancy planning, management, and care through childbirth and postpartum. Women who are cyanotic with oxygen saturation less than 85%, have significant pulmonary arterial hypertension of any cause, or have systemic ventricular dysfunction should be counseled to avoid pregnancy due to a very high risk of maternal and fetal mortality.

[Safety of repeat median sternotomy in the palliative treatment of patients with a univentricular heart]

OBJECTIVE

To establish the morbidity and mortality of patients with univentricular hearts who underwent a repeat median sternotomy at the Instituto Nacional de Pediatría.

METHOD

A retrospective review was performed on the clinical charts of all patients who underwent a repeat median sternotomy from 2001 to 2016.

RESULTS

Sixty-five patients underwent 76 surgeries by repeat median sternotomy. Fifty-nine patients had a first repeat median sternotomy, with a mean age of 36 months (range: 4-176 months) and a mean weight of 12.2 kg (range: 3.2-21.5 kg). Forty patients had a Glenn procedure, and 19 patients had a Fontan procedure. There were 17 patients with a second repeat median sternotomy, with a mean age of 89 months (range 48-156 months), and a mean weight of 22.7 kg (14.4-41 kg). A Fontan procedure was performed on all these 17 patients. A section of the right coronary artery with electrocardiographic changes and a right atrium tear that caused hypotension occurred during first repeat sternotomy. An aortic tear occurred during a second repeat sternotomy with massive bleeding and subsequent death. This represents 3.9% of re-entry injuries.

CONCLUSION

It is concluded that repeat median sternotomy is a safe procedure.

Noninvasive Assessment of Pulmonary Artery Pressure in Patients with Extracardiac Conduit Total Cavopulmonary Connection

To assess quantitative measurement of mean pulmonary artery pressure (PAP) in extracardiac total cavopulmonary connection (TCPC) patients by noninvasive echocardiographic inferior vena cava collapsibility index (IVC-CI) and also correlation between the peripheral vein pressure and mean PAP. In 19 TCPC patients with at least 1-year follow-up after completion of TCPC, complete echocardiography including IVC-CI was recorded. All patients underwent cardiac catheterization for mean PAP pressure, peripheral vein pressure (PVP) and contrast study. Different cutoff points of mean PAP were analyzed, and based on the highest cutoff point, patients were categorized into two groups: mean PAP < 17 mmHg (acceptable) and > = 17 mmHg (high) for comparison analysis. Between 2006 and 2015, from 43 patients who had undergone TCPC, nineteen patients with a mean age 12.9 ± 6.6 years and mean follow-up time of 3.4 ± 1.9 years were included in this study. Mean PAP was 14.6 ± 3.97 (range 8-22 mmHg). Thirteen (68 %) patients had PAP < 17 mmHg. No significant statistical difference was detected with respect to age, sex, type of congenital heart disease and fenestration between these two groups. But, right ventricular dominancy was more prevalent in the high PAP group (50 % vs. 7.7 % P value 0.03). IVC-CI had a correlation with mean PAP (r 0.67, P < 0.001). IVC-CI < 21.8 % can predict PAP > = 17 mmHg with 83 % sensitivity and 100 % specificity. Regression analysis proposed an equation for PAP measurement: PAP (mmHg) = 20.2097-0.1796 × (IVC-CI), (r2 = 0.56). Peripheral vein pressure measurement also showed a good correlation with mean PAP and may be used to estimate PAP with the following equation: PAP (mmHg) = 0. 8675 × PVP, (r 0.90, P < 0.0001). In conclusion, IVC-CI as noninvasive and peripheral vein pressure measurement as a minimal invasive method may be useful for quantitative estimation of PAP in patients with extracardiac TCPC.

Anaesthesia for a minor procedure in a patient with fontan physiology

Fontan procedure is a palliative surgery done for patients born with single ventricle physiology. An understanding of the hemodynamic alterations in such a patient is important for successful perioperative management. We have discussed the anaesthetic considerations in a 12 year-old girl with complex congenital heart disease ultimately palliated by a Fontan operation, who was posted for Botox injections for upper limb spasticity under general anaesthesia.