The Adult With Fontan Physiology: Systematic Approach to Perioperative Management for Noncardiac Surgery

Eagle, Susan; Daves, Suanne M.

doi:10.1053/j.jvca.2010.12.003

Cited by 42 publications

(61 citation statements)

References 141 publications

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“…1 Compared with the general population, ACHD patients have higher rates of healthcare utilization, including hospitalization and surgery. 2 National consensus guidelines for noncardiac surgery 3 and the care of ACHD patients 4 as well as expert reviews [5][6][7] posit that ACHD patients are at increased risk of perioperative complications when they undergo noncardiac surgery. However, although some series have demonstrated an increased perioperative risk in children with congenital heart disease having noncardiac surgery, 8 few clinical outcome data are available in adults.…”

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confidence: 99%

Perioperative Outcomes of Major Noncardiac Surgery in Adults with Congenital Heart Disease

et al. 2013

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Background: An increasing number of patients with congenital heart disease are surviving to adulthood. Consensus guidelines and expert opinion suggest that noncardiac surgery is a high-risk event, but few data describe perioperative outcomes in this population. Methods: By using the Nationwide Inpatient Sample database (years 2002 through 2009), the authors compared patients with adult congenital heart disease (ACHD) who underwent noncardiac surgery with a non-ACHD comparison cohort matched on age, sex, race, year, elective or urgent or emergency procedure, van Walraven comborbidity score, and primary procedure code. Mortality and morbidity were compared between the two cohorts. Results: A study cohort consisting of 10,004 ACHD patients was compared with a matched comparison cohort of 37,581 patients. Inpatient mortality was greater in the ACHD cohort (407 of 10,004 [4.1%] vs. 1,355 of 37,581 [3.6%]; unadjusted odds ratio, 1.13; P = 0.031; adjusted odds ratio, 1.29; P < 0.001). The composite endpoint of perioperative morbidity was also more commonly observed in the ACHD cohort (2,145 of 10.004 [21.4%] vs. 6,003 of 37,581 [16.0%]; odds ratio, 1.44; P < 0.001). ACHD patients comprised an increasing proportion of all noncardiac surgical admissions over the study period (P value for trend is <0.001), and noncardiac surgery represented an increasing proportion of all ACHD admissions (P value for trend is <0.001). Conclusions: Compared with a matched control cohort, ACHD patients undergoing noncardiac surgery experienced increased perioperative morbidity and mortality. Within the limitations of a retrospective analysis of a large administrative dataset, this finding demonstrates that this is a vulnerable population and suggests that better efforts are needed to understand and improve the perioperative care they receive.

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confidence: 99%

Perioperative Outcomes of Major Noncardiac Surgery in Adults with Congenital Heart Disease

et al. 2013

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“…Theoretically, OLV has several detrimental effects in patients with Fontan circulation. The physiological changes associated with OLV, such as hypercarbia, hypoxia, and hypoxic pulmonary vasoconstriction (HPV), disturb the blood flow to the pulmonary circulation through elevation of the PVR [7,8,11,12]. 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].…”

Section: Discussionmentioning

confidence: 99%

“…The physiological changes associated with OLV, such as hypercarbia, hypoxia, and hypoxic pulmonary vasoconstriction (HPV), disturb the blood flow to the pulmonary circulation through elevation of the PVR [7,8,11,12]. 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].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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Background: Surgeries requiring one-lung ventilation (OLV) in patients with Fontan circulation pose great challenges. However, little information is available regarding the safety of OLV in Fontan patients when hemidiaphragmatic paralysis is present. Case presentation: A 41-year-old woman who underwent repeated Fontan procedures was re-admitted to our hospital because of worsening shortness of breath. As left hemidiaphragmatic paralysis was considered to be contributing to her symptom, an open thoracic left diaphragmatic plication surgery was scheduled. A preoperative pulmonary artery angiogram revealed a remarkably reduced blood flow to the left lung. The surgeon requested OLV during the surgery. Despite our concern regarding the impact of OLV on the Fontan circulation, OLV did not result in major hemodynamic changes. Conclusion: OLV can be safely implemented in patients with hemidiaphragmatic paralysis with preserved Fontan circulation. Preoperative pulmonary artery angiography may provide useful information for estimating the impact of OLV on the Fontan circulation.

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“…Positive pressure ventilation with increased intrathoracic pressures not only reduces the passive pulmonary flow and the cardiac output but also causes fluctuations in atrial pressure and volume, which can dislodge the ablation catheter. When using positive-pressure ventilation, a ventilator strategy of lower mean airway pressure, moderate alkalosis (pH=7.45, PCO 2 =35 mm Hg), tidal volumes of 5–6 mL/kg, short inspiratory times and low PEEP usually allow adequate pulmonary blood flow with minimal haemodynamic effects 24. Choosing a spontaneous breathing mode may facilitate passive pulmonary flow and improves the cardiac output in Fontan patients.…”

Section: Discussionmentioning

confidence: 99%

“…Resuscitation and supportive cardiac drugs should be prepared prior to induction of anaesthesia. Intravenous inodilators such as milrinone are well suited for the Fontan patient due to their lusitropic and pulmonary vasodilatory properties, helping to improve ventricular compliance without raising CVP 24. Vigilance is necessary to watch out for potential complications of catheter ablation, which include cardiac tamponade, pericardial effusion, thromboembolism, complete atrioventricular block and atrio-oesophageal fistula 20 22…”

Section: Discussionmentioning

confidence: 99%

Anaesthetic management of a patient with Fontan physiology for electrophysiology study and catheter ablation

2019

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The success of the Fontan procedure for congenital single ventricle anatomy has resulted in adult patients with Fontan physiology requiring anaesthesia for cardiac and non-cardiac procedures. We present the perioperative management of a patient with Fontan physiology who underwent electrophysiological study with radiofrequency ablation for atrial tachycardia under general anaesthesia. Good communication between the multidisciplinary teams, a detailed understanding of the patient’s complex cardiac anatomy and physiology, as well as the ability to recognise and manage perioperative complications all play a vital role for a successful outcome.

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The Adult With Fontan Physiology: Systematic Approach to Perioperative Management for Noncardiac Surgery

Cited by 42 publications

References 141 publications

Perioperative Outcomes of Major Noncardiac Surgery in Adults with Congenital Heart Disease

Perioperative Outcomes of Major Noncardiac Surgery in Adults with Congenital Heart Disease

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

Anaesthetic management of a patient with Fontan physiology for electrophysiology study and catheter ablation

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