Perioperative Management of Infants Undergoing Fundoplication and Gastrostomy After Stage I Palliation of Hypoplastic Left Heart Syndrome

Abstract

Infants with hypoplastic left heart syndrome (HLHS) represent a high-risk population when they present for noncardiac surgery. To assist clinicians in the care of these infants, we present our experience of 36 HLHS patients who underwent abdominal surgery after stage I palliation. We reviewed patients with HLHS who underwent gastrostomy and/or fundoplication after stage I palliation during an 18-month period. We assessed the impact of preoperative echocardiographic predictors and regional anesthesia on use of intraoperative inotropes, extubation in the OR, perioperative instability, postoperative escalation of care, and length of hospital and intensive care unit stay. Of 39 abdominal operations, all but 2 were performed with open laparotomy. There was a positive association between regional anesthesia and instability during induction. Escalation of respiratory care occurred in 9 (23.1%) cases, and escalation of hemodynamic care occurred in 6 (15.4%) cases. Neoaortic valve insufficiency was associated with increased length of stay, and ventricular outflow obstruction was associated with escalation of hemodynamic care. Extubation in the OR was successful in 31 cases (79.5%). In-hospital death occurred in 1 patient (2.7%). HLHS infants often undergo abdominal surgery, but intraoperative instability and need for escalation of care is common. Specific echocardiographic findings were associated with length of stay and escalation of care. Regional anesthesia was associated with transient intraoperative instability but not with other adverse outcomes.

Liver transplantation after stage II palliation for hypoplastic left heart syndrome

“…Noncardiac surgery during this period should be avoided and restricted to emergent procedures . Gastrostomy with fundoplication is one of the frequently performed procedures after stage I palliation, and the reported mortality rate is 0% to 19% . In this case, the decision to perform the Kasai procedure was made before the patient was transferred to our center.…”

“…During stage III (the Fontan operation), when the children are 2 to 3 years old, the final arrangement for the single‐ventricle pathway is established . The interstage period is associated with significant mortality . These children are challenges for noncardiac surgical procedures because the single‐ventricle physiology responds poorly to abrupt hemodynamic changes such as those occurring in the setting of LT .…”

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

“…However, all of these articles make excellent points that can help guide the perioperative care of these delicate patients [20][21][22][23][24]. The stability of this stage must be weighed against the need for adequate nutrition and the avoidance of gastroesophageal reflux.…”

“…Outcomes in patients with HLHS after the Norwood procedure undergoing open fundoplication were reported by Garey et al [23] in 39 patients over 19 years. Watkins et al [24] reviewed the perioperative management of 39 abdominal operations performed at a single institution on post-Norwood patients with HLHS. [23].…”

“…There were postoperative complications in 41% of this patient group and 30-day mortality was 4%. There were a number of patients requiring an escalation in care postoperatively, and as a review of these events, the institution made a practice change to have all post-Norwood HLHS patients recover from noncardiac surgery in an intensive care setting [24]. Watkins et al [24] reviewed the perioperative management of 39 abdominal operations performed at a single institution on post-Norwood patients with HLHS.…”