Anaesthetic management of a patient with Gerbode defect

Abstract

Gerbode defect is a rare left ventricle to right atrium shunt that can be acquired or congenital. The incidence of acquired defects has been growing and is caused by previous cardiac surgery, endocarditis, trauma and myocardial infarct. It can be challenging and the anesthesiologist should maintain a suspicion when there is circulatory failure after a cardiac surgery. It can be diagnosed by trans-esophageal echocardiography. In this case we presented the anesthetic management and the successful surgical correction of an acquired ventricular-atrial defect secondary to a previous mitral valve replacement.

Congenital Gerbode Defect: A Left Ventricular to Right Atrial Shunt—State-of-the-Art Review of Its General Data, Diagnostic Modalities, and Treatment Strategies

“…In addition, the increased right ventricular preload causes pulmonary circulation overload with a subsequent volume loading and enlargement of the left heart cavities [ 1 , 33 , 38 ]. Thus, in the case of a significant shunt with therapeutic delay, the acyanotic Gerbode defect [ 44 ] may result in dilatation of all cardiac cavities, pulmonary artery hypertension and congestion, as well as low cardiac output and a decline in global cardiac function [ 11 , 50 ].…”

“…The extent of symptomatology depends on the size of the defect and the volume and duration of the LV-RA shunt [ 7 , 12 ]. The systematic literature review by Yuan [ 5 ] reported that more than 25% of patients suffering from the congenital Gerbode defect were asymptomatic in the context of incidental findings, whereas dyspnea, systolic heart failure, and fever accounted for the prevalent clinical manifestations [ 50 ]. Dyspnea is caused by pulmonary arterial hypertension with congestion.…”

“…TEE can be used to more accurately visualize the anatomic location and direction of the shunt, as well as to avoid diagnostic errors like a ruptured sinus of Valsalva, VSD, and tricuspid regurgitation [ 6 ]. The most suitable views to display the LV-RA shunt are described as the midesophageal four4- chambers view, midesophageal right ventricle inflow–outflow view, and midesophageal reversed four4 -chamber view (130–160°) [ 50 ].…”

“…During device closure, residual shunts, new or increased tricuspid regurgitation, dislocation of the device, and intra- and post-procedural atrioventricular block frequently occur [ 31 , 40 , 50 ]. A transient or permanent complete heart block is a frequently observed complication of transcatheter closure, which is described to occur immediately after device implantation.…”

“…If left untreated, the left-to-right shunt can result in early and progressive heart failure with hemodynamic deterioration, exercise intolerance, cardiac chamber enlargement, and valve destruction along with an annular abscess, usually within six months [ 5 , 50 , 69 ]. The study by Chou et al indicated an association between an LV-RA shunt presenting with right atrial enlargement and the presence of atrial fibrillation.…”