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Department of Anesthesiology, School of Medicine, Washington University of St. Louis, Department of Surgery, University of Pisa, Pisa, Italy, cattanod{at}msnotes.wustl.edu (Cattano) Department of Anesthesia and Intensive Care, AUSL 12 Versilia Hospital, Lido di Camaiore (Lu), Italy (Nicolini, Genovesi, Buzzigoli)
To the Editor:
We read with interest the review articles by Russell et al. (1) and McGowan (2), on the perioperative issues regarding an adult patient with a corrected congenital heart disease (CHD). Because of the reduction in mortality after complex CHD correction, these patients may be presenting more frequently for noncardiac surgery (inguinal hernia repair, cholecystectomy, etc). In particular, laparoscopic surgery can increase the risks associated with the physiology of corrected CHD (3). Although guidelines and recommendations for management have been suggested, we were unable to find reports of current practice in these patients. We report a laparoscopic cholecystectomy in an adult patient with corrected CHD.
A 21-yr-old female (body weight 50 kg) with a fenestrated Fontan Goretex conduit, presented to a second level regional hospital for an elective cholecystectomy after repetitive biliary colics (gallbladder stones). She was otherwise healthy, working, and functionally active. She had had three different operations between her neonatal and teenage years for dextrocardia, univentricular heart, transposition of the great vessels, tricuspid atresia, and pulmonary hypoplasia. These were treated by a bicavo-pulmonary anastomosis and fenestration of 5 mm (atrial septal defect left open for reducing pulmonary and systemic venous hypertension).
A preoperative transthoracic echocardiogram and cardiac catheterization showed normal ventricular function, inferior vena cava pressure 16 mm Hg, left ventricular end-diastolic pressure 10 mm Hg and moderate valvular insufficiency, minimal inferior vena cava stasis with no liver enlargement, preserved superior vena cava blood flow, and slight cyanosis. Her cardiac rhythm was regular except for rare supraventricular extra systoles. She was taking no medications other than salicylate.
After considerable preoperative discussion, the patient was scheduled for a cholecystectomy via a laparoscopic approach. It was decided to insert neither a central line nor a Swan Ganz catheter, so as to prevent puncture or infection of the Goretex conduit between the cavae, and because of the potential for right to left heart catheter migration or arrhythmogenesis. The patient was admitted for preoperative hydration (1 L Ringer’s lactate solution during the 6 h before surgery). An arterial catheter was placed for arterial blood pressure (BP) monitoring. Transesophageal echocardiography (TEE) was not available. The perioperative issues and consequent goals were to optimize preload, reduce the pneumoperitoneum (using low pressure: 8 mm Hg low flow over 10 minutes), maintain pulmonary blood flow and cardiac output (use of colloid for intraoperative intravascular fluid replacement, use Trendelenburg positioning), avoid arrhythmias, and minimize intrathoracic pressure by using low-pressure ventilation (pressure-controlled mechanical ventilation set at 13 cm H2O (TV 500 mL) and respiratory rate 14 with O2 at 60%).
General anesthesia was induced with propofol 1 mg/kg, fentanyl 1µg/kg and atracurium 0.5 mg/kg after 0.1 mg/kg of diazepam as premedication, and maintained with sevoflurane 1%–1.5% in air/oxygen and fentanyl 1 µg/kg/h. At induction, moderate hypotension was observed (80/50 heart rate (HR) 120 compared with preinduction BP 130/70 HR 100) and corrected by infusion of 250 mL of 6% hetastarch over 5 min and hetastarch 20 mL/kg/h continuous infusion. The overall surgical time was 22 min. The patient required hetastarch 30 mL/kg/h in the 2 h after surgery for minor hypotension. She was admitted, as a precaution, to the intensive care unit. After 6 h of continuous stable monitoring she was transferred to the ward.
The physiology of adult corrected CHD is delicate and dependent on venous return and pulmonary blood flow. In general the principles of care we adopted conformed to the ones outlined recently by McGowan (preoperative optimization; evaluation of residual CHD problems such as contractile dysfunction, abnormal hemodynamic loading, pulmonary hypertension, end organ dysfunction, and sequelae related to partially corrected defects; intraoperative care to maximize venous return, reduce intrathoracic pressure by judiciously controlled positive pressure, and avoid hypoxia and hypercarbia that increase pulmonary vascular resistance) (2). However we decided to not place a central line or pulmonary artery catheter. Intraoperative TEE was not available for our patient, but it can potentially replace a Swan Ganz catheter and offer real-time evaluation of the physiologic modifications occurring in these patients. The laparoscopic approach in this case resulted in a positive outcome, and in principle can offer advantages such as reduced pain, surgical stress (which might increase pulmonary resistance) risk of hemorrhage and infection, and faster discharge. The reverse Trendelenburg laparoscopic approach can, however, constitute a challenge for both the anesthesiologist (due to the physiologic changes of mechanical ventilation, anesthetic-induced changes in vascular tone and cardiac rhythm, and pneumoperitoneum) and the surgeon (due to lower than conventional insufflation pressures and pneumoperitoneum and reverse rather than normal Trendelenburg). The choice of a laparoscopic versus traditional open approach should be considered case by case.
REFERENCES
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