Anesthetic Management of Congenital Heart Disease “Right to Left Shunt” In Adults Undergoing Non Cardiac Surgery

Abstract

Adult congenital heart diseases (ACHD) have become more prevalent in the surgical population and so can be encountered in the daily practice. Adult patients with congenital heart disease present the anesthetist with unique and varied challenges. Individualized care of these fragile patients should be approached with a keen understanding of the patient’s underlying cardiac anomaly. Due to the variable nature of ACHD with R-to-L shunts, perioperative anesthetic care should be considered as a multi-disciplinary strategy in order to improve the management and outcome of patients undergoing surgery and to come up with a safe interdisciplinary peri-procedure plan with better surgical and medical outcome. Anesthesiologists as perioperative physicians play a key role in non-cardiac surgery of R-to-L shunt patients, through their choice of preoperative medication, anesthetics and techniques as well as the administration of adjunctive drugs to maintain major organ system function during and after surgery. In preoperative assessment, the ACHD patient's history may be incomplete or misleading due to misapprehension of "cure" while in fact active issues still remain and impact importantly the management plans. Patients with congenital heart disease (CHD) are also susceptible to the acquired cardiovascular and non-cardiovascular diseases that accrue with age. The patient's cardiac functional status is assessed from history and preoperative investigations - including routine labs plus a good review of cardiac anatomy via echocardiography (with shunt and clot check) and cardiac catheterization -which are recommended as they might modify the contemplated procedure, the anesthetic technique or the nature of monitoring. The main preoperative role is to optimize the patient for the planned intervention as much as possible and to manage perioperative anticoagulation and cardiac medications, in addition to the preoperative choice of suitable monitoring and adequate technique and mode of ventilation. These are all critically essential to positively influence the postoperative outcome in ACHD patients.