Successful one-lung ventilation in a patient with the Fontan circulation undergoing thoracotomy: a case report

Abstract

The incidence of noncardiac surgery in patients with the Fontan circulation has increased over the years due to the elongated life expectancy of these patients. In patients with the Fontan circulation, pulmonary blood flow is passive, so it is important to keep pulmonary vascular resistance low. One-lung ventilation (OLV) can have adverse effects on the Fontan circulation due to hypoxia, hypoxic pulmonary vasoconstriction, hypercarbia, and increased airway pressure. We present a case of successful OLV in a patient with the Fontan circulation and describe our perioperative management.

One-lung ventilation in a patient with Fontan circulation undergoing diaphragmatic plication surgery: a case report

“…Moreover, the rise in the intrathoracic pressure due to the high positive pressure ventilation during OLV also potentially interferes with the systemic venous return in patients with Fontan circulation [12]. In previous case reports, OLV indeed resulted in the disruption of Fontan circulation, manifesting as severe hypotension, elevated CVP, and elevated PVR, necessitating the use of vasopressors and inotropes [9,10].…”

“…Contrary to these precedents, however, we did not encounter any major difficulties in the management of OLV in this patient. Given the limited number of available reports [9,10,13], it remains difficult to predict in which patients with Fontan circulation OLV would carry a higher risk of hemodynamic instability.…”

“…Lending support to such concerns, previous case reports have documented disruption of Fontan circulation during OLV in patients undergoing thoracic surgeries [9,10]. On the other hand, little information is available regarding the safety of OLV in Fontan patients specifically when hemidiaphragmatic paralysis is present.…”

Glenn procedure in a baby with single pulmonary artery and single lung

“…This makes one-lung ventilation one of the most important events and nitroglycerin, inhaled nitric oxide, and intravenous milrinone may be used in management to decrease pulmonary vascular resistance. [8]…”

Successful One-Lung Ventilation in a Patient With the Fontan Circulation Undergoing Thoracoscopic Procedure

“…It is imperative to keep the PVR low in patients with Fontan circulation during OLV in order to maintain adequate pulmonary blood flow and cardiac output. 3 PVR is an important determinant of cardiac output in the Fontan circulation, where the systemic circulation is in series with the pulmonary circulation without any intervening of the right ventricle. 4,5 To prevent the development of pulmonary hypertension, care should focus on elimination of painful stimuli, which can cause pulmonary vasoconstriction, along with interventions that promote pulmonary vasodilation.…”