Anesthesia in adults with congenital heart disease

Anesthetic Considerations for Adult Patients With Both Down Syndrome and Congenital Heart Disease Undergoing Noncardiac Surgery: A Review Article

The population of adult patients with both Down syndrome and congenital heart disease is increasing due to better medical and surgical care. This cohort presents with multiple unique comorbidities, secondary to both progressions of health conditions associated with the aging of patients with Down syndrome, as well as due to pathophysiologic effects of uncorrected, corrected, or palliated congenital heart disease. These patients need frequent medical care and interventions requiring multiple anesthetics. This review focuses on the various factors relevant to the perioperative medical care of adult patients with both Down syndrome and congenital heart disease, founded on existing literature. Various anesthetic considerations for the different patterns of noncardiac and cardiac comorbidities are reviewed, and a systematic approach for the perioperative anesthetic management of these patients is presented.

Anesthetic Management in Adults with Congenital Heart Disease

PURPOSE OF REVIEW

Adults with congenital heart disease (ACHD) are a complex and growing population that presents numerous challenges for anesthetic management. This review summarizes special considerations for anesthetic management in ACHD.

RECENT FINDINGS

The adult patient with congenital heart disease may require anesthetic care for multiple surgeries and interventions throughout their lifetime. The cardiac and extracardiac manifestations of ACHD have important perioperative implications that affect anesthetic management. Recent American Heart Association/American College of Cardiology and European Society of Cardiology guidelines endorse a multidisciplinary, team-based approach to care. The cardiac anesthesiologist, endorsed as part of this multidisciplinary team, must have a thorough understanding of congenital heart disease pathophysiology and common extra-cardiac manifestations of ACHD. Safe anesthetic management in adult congenital heart disease should incorporate a multi-disciplinary approach to patient care. Anesthesiologists and centers with special expertise in ACHD care should be utilized or consulted whenever possible.

Perioperative care of adults with Down syndrome: a narrative review

Because of enhanced life expectancy due to medical and surgical therapeutic advances, it is estimated that there are more adults than children living with Down syndrome (DS), or trisomy 21, in the United States. Therefore, DS can no longer be considered a syndrome limited to the pediatric population. These patients are presenting for surgery and anesthesia in adult care settings, where anesthesiologists will encounter these patients more frequently. As these patients age, their commonly associated co-morbidities not only progress, but they also develop other cardiac, respiratory, gastrointestinal, and neurologic conditions. The manifestations and consequences of chronic disease can present new challenges for the anesthesiologist and require expertise and judgement to minimize patient risk. The purpose of this narrative review is to describe the common pediatric co-morbidities associated with DS and discuss the age-acquired manifestations. Additionally, considerations for anesthetic care of the adult with DS will be presented, including the preoperative assessment, intraoperative management, and postoperative care.

Effect of remifentanil-based fast-track anesthesia on postoperative analgesia and sedation in adult patients undergoing transthoracic device closure of ventricular septal defect

Objective

To investigate the effect of remifentanil-based fast-track anesthesia on analgesia and sedation after transthoracic device closure of ventricular septal defects (VSDs) in adult patients.

Methods

A retrospective analysis was performed on 59 patients aged 21–53 years who underwent transthoracic device closure of VSDs from January 2019 to September 2019. According to the different anesthesia strategies, the patients were divided into the R group (using remifentanil-based anesthesia, n = 33) and the S group (using sufentanil-based anesthesia, n = 26). Patient-related clinical data, postoperative analgesia, and sedation scores were collected and analyzed.

Results

There was no significant difference in age, gender, body weight, and operation time between the group R and the group S (P > 0.05). There was also no significant difference in intraoperative hemodynamic changes, BIS scores, postoperative analgesia, and sedation scores between the two groups (P > 0.05). The duration of mechanical ventilation, the length of ICU stay, and hospital stay in the group R were significantly lower than those in the group S (P < 0.05).

Conclusion

Remifentanil-based fast-track anesthesia is effective for adult patients undergoing transthoracic device closure of VSDs, which may shorten the mechanical ventilation duration, the ICU and hospital stay of patients.

Adult congenital heart disease and the COVID-19 pandemic

Adults with congenital heart disease (ACHD) may be at high risk in the case of COVID-19. Due to the heterogeneity of ACHD and secondary complications, risk profiles are, however, not uniform. This document aims to give an overview of relevant data and outline our pragmatic approach to disease prevention and management. Based on anatomy and additional physiological factors including symptoms, exercise capacity, heart failure, pulmonary hypertension and cyanosis, we propose a pragmatic approach to categorising patients into low-risk, intermediate-risk and high-risk groups. We regard especially patients with complex cyanotic conditions, those with palliated univentricular hearts, heart failure, severe valvular disease or pulmonary hypertension as high-risk patients. To avoid infection, we recommend self-isolation and exemption from work for these cohorts. Infected ACHD patients with low or moderate risk and without signs of deterioration may be remotely followed and cared for at home while in self isolation. High-risk patients or those with signs of respiratory or cardiovascular impairment require admission ideally at a tertiary ACHD centre. Especially patients with complex, cyanotic disease, heart failure and arrhythmias require particular attention. Treatment in patients with cyanotic heart disease should be guided by the relative degree of desaturation compared with baseline and lactate levels rather than absolute oxygen saturation levels. Patients with right heart dilatation or dysfunction are potentially at increased risk of right heart failure as mechanical ventilation and acute respiratory distress syndrome can lead to increase in pulmonary arterial pressures.

Heart Failure in Adult Patients with Congenital Heart Disease

Adult patients with congenital heart disease are a complex population with a variety of pathophysiologic conditions based on the anatomy and type of surgery or intervention performed, usually during the first years of life. Nowadays, the majority of patients survive childhood and present for a number of noncardiac surgeries or interventions needing appropriate perioperative management. Heart failure is a major contributing factor to perioperative morbidity and mortality. In this review, we present an overview of the most common types of adult patients with congenital heart disease and actual knowledge on therapy and specific risks in this challenging patient population.

[Non-cardiac surgery in adults with congenital heart defects : Most important parameters in anesthesia management]

BACKGROUND

Adults with congenital heart disease (CHD) represent an increasing proportion of patients undergoing non-cardiac surgery.

OBJECTIVE

To identify the most important parameters for management of anesthesia.

MATERIAL AND METHODS

Evaluation and discussion of the current original research and guideline recommendations.

RESULTS

There are approximately 300,000 patients with CHD living in Germany. The preoperative evaluation is an important influencing factor affecting perioperative morbidity and mortality. Echocardiography is the key instrument for identifying cardiac conditions predisposing to adverse events. The subdivision of CHD into lesions with left-to-right shunt, obstructive lesions and complex congenital heart diseases facilitates the classification of the pathophysiology.

CONCLUSION

Decisive for the perioperative outcome of patients with CHD are the identification of high-risk patients, understanding of the individual situation with respect to the underlying pathophysiology and the intraoperative maintenance of cardiac output.

Anomalous Drainage of Inferior Vena Cava into the Left Atrium

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Noteworthy Literature published in 2017 for Congenital Cardiac Anesthesiologists

This review focuses on the literature published during the 13 months from December 2016 to December 2017 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Five themes are addressed during this time period and 100 peer-reviewed articles are discussed.

Management of the Critically Ill Adult With Congenital Heart Disease

Survival of adults with congenital heart disease (CHD) has improved significantly over the last 2 decades, leading to an increase in hospital and intensive care unit (ICU) admissions of these patients. Whereas most of the ICU admissions in the past were related to perioperative management, the incidence of medical emergencies from long-term sequelae of palliative or corrective surgical treatment of these patients is rising. Intensivists now are confronted with patients who not only have complex anatomy after congenital cardiac surgery, but also complex pathophysiology due to decades of living with abnormal cardiac anatomy and diseases of advanced age. Comorbidities affect all organ systems, including cognitive function, pulmonary and cardiovascular systems, liver, and kidneys. Critical care management requires an in-depth understanding of underlying anatomy and pathophysiology in order to apply contemporary concepts of adult ICU care to this population and optimize patient outcomes. In this review, the main CHD lesions and their common surgical management approaches are described, and the sequelae of CHD physiology are discussed. In addition, the effects of chronic comorbidities on the management of critically ill adults are explored, and the adjustments of current ICU management modalities and pharmacology to optimize care are discussed.