Adult congenital heart disease

Catheter Ablation: General Principles and Advances

Besides antiarrhythmic medication, there are now very good options for a potentially curative therapy by catheter ablation targeting the origin of the underlying arrhythmias in patients with complex congenital heart disease. Three-dimensional (3D) reconstruction of tomographic imaging (MRI or computed tomography) is helpful to understand the underlying cardiac anatomy, identify the most likely target chamber, and help with planning access. Use of the available 3D mapping systems (sequential or simultaneous acquisition) and (if available) more advanced navigation systems, such as remote magnetic navigation, can improve the acute and long-term outcomes of catheter ablation in congenital heart disease.

The impact of liver disorders on perioperative management of reoperative cardiac surgery: a retrospective study in adult congenital heart disease patients

PURPOSE

We evaluated the preoperative prevalence of risk factors for liver disorders and the relationship between the liver disorders and perioperative outcomes in adult congenital heart disease (ACHD) patients.

METHODS

This retrospective study included 32 ACHD patients who underwent reoperative cardiac surgery.

RESULTS

Preoperatively, 38% of the study patients had risk factors, including congestive liver (CL) due to right heart failure (31%), chronic hepatitis C (HC) (22%), and both CL and HC (16%). The numbers of patients with Child-Pugh scores 5, 6, 7 and 8 were 22, 7, 2 and 1. Median (range) preoperative platelet count and fibrinogen values were 155 (61-330) × 10³/μl and 250 (145-367) mg/dl, respectively. The patients with higher Child-Pugh scores tended to have longer duration of anesthesia and surgery (p = 0.078, 0.078, respectively), and had significantly higher platelet transfusion (p = 0.031). Lower platelet count was associated with longer duration of anesthesia, surgery and cardio pulmonary bypass (CPB), and larger amount of blood loss and platelet transfusion (p = 0.01, 0.011, 0.024, 0.033, 0.021). Lower fibrinogen value was associated with longer duration of anesthesia, surgery and CPB, and larger amount of platelet transfusion (p = 0.015, 0.009, 0.009, 0.023).

CONCLUSION

ACHD patients who underwent reoperative cardiac surgery had a high prevalence of risk factors for liver disorders preoperatively, and liver disorders aggravated some intraoperative outcomes. These findings suggest that the prevention of liver disorders is important for reducing the occurrence of poor outcomes, and that ACHD patients with liver disorders need attentive perioperative management.

Anaesthetic management of breast surgery in a patient with Eisenmenger syndrome

Eisenmenger syndrome (ES) is a complex combination of cardiovascular abnormalities defined as pulmonary hypertension with investment or bidirectional flow through an intracardiac or aortopulmonary communication, usually secondary to a congenital heart disease not resolved promptly. It carries a significant risk of perioperative mortality, with an incidence close to 30% for non-cardiac surgery. We report the anaesthetic management in a ES patient undergoing breast surgery, which was successfully performed under general anaesthesia combined with thoracic analgesic blocks. The main pathophysiological implications of this syndrome are discussed, emphasizing the importance of appropriate preoperative evaluation with thorough assessment of associated risks, careful intraoperative management, and postoperative care, which should be initially performed in a critical care unit. The need to individualize and tailor the choice of drugs and anesthetic technique to the hemodynamic condition of the patient and the surgical procedure is highlighted.

Anesthesia and the pediatric cardiac catheterization suite: a review

Advances in technology over the last couple of decades have caused a shift in pediatric cardiac catheterization from a primary focus on diagnostics to innovative therapeutic interventions. These improvements allow patients a wider range of nonsurgical options for treatment of congenital heart disease. However, these therapeutic modalities can entail higher risk in an already complex patient population, compounded by the added challenges inherent to the environment of the cardiac catheterization suite. Anesthesiologists caring for children with congenital heart disease must understand not only the pathophysiology of the disease but also the effects the anesthetics and interventions have on the patient in order to provide a safe perioperative course. It is the aim of this article to review the latest catheterization modalities offered to patients with congenital heart disease, describe the unique challenges presented in the cardiac catheterization suite, list the most common complications encountered during catheterization and finally, to review the literature regarding different anesthetic drugs used in the catheterization lab.

Anesthetic management of pulmonary valve replacement for pulmonary regurgitation in six patients with surgically repaired tetralogy of Fallot

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease (CHD) encountered in CHD patients surviving into adulthood. A number of patients with surgically repaired TOF have significant pulmonary regurgitation (PR) that can lead to right ventricular (RV) dilatation, RV failure, and arrhythmia. We describe the anesthetic management for pulmonary valve replacement (PVR) in six PR patients with surgically repaired TOF. Although all patients had dilated RVs and depression of RV ejection fraction preoperatively, and arrhythmia and unexpected bleeding perioperatively, they could tolerate a well-managed PVR operation. Anesthesiologists should be aware of the multiplicity of comorbidities, sequelae, and residua in patients with surgically repaired TOF. RV function should be monitored using transesophageal echocardiography, and inotropic vasodilators and alpha-adrenergic agents should be administered, as appropriate. Arrhythmias, vascular injury during removal of adhesions during re-sternotomy, and bleeding from collateral vessels are also frequent complications.

Anesthesia for the patient with congenital heart disease presenting for noncardiac surgery

PURPOSE OF REVIEW

To summarize recent publications emphasizing the changes in the population of patients with congenital heart disease and trends in the anesthetic and perioperative care of these patients presenting for noncardiac procedures.

RECENT FINDINGS

It has been reported that children with congenital heart disease presenting for noncardiac surgery are at an increased anesthetic risk. This risk has become better defined. The patients at highest risk are infants with a functional single ventricle and patients with suprasystemic pulmonary hypertension, left ventricular outflow tract obstruction or dilated cardiomyopathy. Familiarity with the physiology and perioperative implications of the stages of single ventricle palliation is critical. The anesthetic approach, monitoring, conduct of surgery and postoperative care and outcomes are variable in this patient population. Recent literature reflects the growing number of children with ventricular assist devices and the management of these patients for noncardiac procedures. Cardiac imaging modalities provide diagnostic information, and strategies for reducing anesthetic risk for these procedures are of great interest. Pharmacologic trends and the application of technology are reviewed.

SUMMARY

The identification of high-risk patients, multidisciplinary decision-making and planning and careful anesthetic management and monitoring are critical for optimizing outcomes in children with congenital heart disease presenting for noncardiac procedures.

[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.