Anesthesia for Adult Patient with Congenital Heart Disease

1. Anesthesia for Adult Patient with Congenital Heart Disease Mohamed Saleh, MD Department of Anesthesia and Intensive Care, Ain-Shams University

2. Case Scenario • A 17 years-old patient, was presented for emergency appendectomy. He had a history of repaired TOF at the age of 2 years. 12 years later, he started to complain of palpitations, exertional dyspnea, and was diagnosed as pulmonary regurgitation and right ventricular dysfunction. • How to manage this patient in the peri-operative period?

3. Introduction

4. Journal of Cardiothoracic and Vascular Anesthesia, Vol 20, No 3 (June), 2006: pp 414-437

6. Arrhythmias

7. Pulmonary hypertension

8. Ventricular dysfunction • Volume Overload • Pressure Overload

9. Hematologic dysfunction • Erythrocytosis • Hyper-viscosity • Iron deficiency anemia

10. Hemostatic Dysfunction • Thrombocytopenia • Platelet function abnormalities • Disseminated intravascular coagulation • Decreased production of coagulation factors • Impaired liver function • Vitamin K deficiency • Primary fibrinolysis

11. Renal dysfunction • Hypercellular glomeruli • Basement membrane thickening • Focal interstitial fibrosis • Tubular atrophy • Hyalinization of afferent and efferent arterioles.

12. Neurologic disease Cerebral emboli / thrombosis Cerebral abscess

13. Common congenital heart diseases

14. Atrial Septal Defect

15. Ventricular Septal Defect

16. Coarctation of the aorta

17. Aortic Stenosis

18. Tetralogy of Fallot

19. Transposition of Great Arteries

20. Univentricular Heart

21. Strategy for management of ACHD patient through non-cardiac surgery

22. Adult Congenital Heart Center

23. Classification of ACHD according to complexity

24. 1- Define the Condition • Primary lesion • Previous palliative and corrective surgeries • Residual and sequelae

25. 2- Assess the Surgical Risk • Predictors and risks of the proposed surgical procedure itself • Specific ACHD risk factors • Other co-morbid conditions

26. 3- Develop a Management Plan • Understanding of anatomy and physiology • Hemodynamic goals • Perioperative management

29. HISTORY & PHYSICAL EXAMINATION • Assess functional status • Symptoms, signs of right sided failure • Symptoms, signsof left sided failure • Symptoms of low cardiac output • Arrhythmias • Cyanosis & its sequelae

31. De-airing • All intravenous lines must be meticulously de-aired. • Patent foramen ovaleis present in approximately 25% of adults

32. Indications for Prophylaxis against IEC in CHD* • Unrepaired cyanotic CHD, including palliative shunts and conduits • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure** • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) • Previous IE • *Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD. • **Prophylaxis is reasonable because endothelialization of prosthetic material occurs within 6 months after the procedure.

33. Premedication Patients often anxious Cognitive impairments Psychosocial issues Premedication with anxiolytics and hypnotics must be undertaken very cautiously.

34. Monitoring Non-invasive Invasive • ECG • NIBP • Pulse oximetry • End tidal capnogram - Art. catheterization - CVP - PAC - TEE

35. Choice of anesthetics • There are no evidence-based recommendations to guide the anesthetic management of patients with CHD undergoing non-cardiac surgery.

36. Intravenous anesthetics

37. Inhalational anesthetics

38. Regional anesthesia

39. Fluid management • Minimizing the NPO interval • Preoperative hydration • Maintenance of adequate intravascular volume • Adjustment of the transfusion threshold.

40. Positioning

41. Positive Pressure Ventilation • Control pulmonary vascular resistance • Reduces systemic venous return, in patients with single ventricle physiology

42. Postoperative Management PACU vs. ICU Major risk factors during the postoperative period: • Bleeding. • Dysrhythmias. • Thromboembolic events.

43. Postoperative Management • Post-operative analgesia • Fluid Management

44. Thank you