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Published on: May 2, 2025
[Criss-cross heart: anesthetic considerations for total cavopulmonary shunt (Fontan procedure)]
A Martínez-Tellería1, M E Cano Serrano, E M Barroso Becerra
1Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de las Nieves (Centro Materno Infantil). Granada. amt@ajr.tiscalibiz.com
Insights
This study details anesthetic management for a complex pediatric heart defect, utilizing hyperventilation to optimize oxygen saturation and reduce pulmonary resistance during a Fontan procedure. The patient recovered well, demonstrating the efficacy of this anesthetic approach.
Area of Science:
- Pediatric Anesthesiology
- Congenital Heart Disease Management
- Cardiovascular Surgery
Background:
- Complex congenital heart disease (CHD) in pediatric patients presents significant anesthetic challenges.
- A 2-year-old girl with multiple cardiac anomalies, including criss-cross heart and transposition of great vessels, required surgical intervention.
- The patient had baseline low arterial oxygen saturation (SapO2) of 65%
Observation:
- Anesthetic induction involved inhaled agents followed by intubation and controlled hyperventilation to maintain end-tidal carbon dioxide around 27 mm Hg.
- General anesthesia was supplemented with spinal morphine for analgesia.
- A total cavopulmonary anastomosis (Fontan procedure) was performed with cardiopulmonary bypass, utilizing milrinone.
- Post-operatively, the patient was extubated within 90 minutes of transfer to the pediatric intensive care unit.
Findings:
- The anesthetic strategy successfully maintained normal arterial pressure.
- Hyperventilation was employed to reduce pulmonary vascular resistance, aiding in adequate preloading.
- The Fontan procedure was completed without intraoperative complications.
Implications:
- This case highlights the importance of tailored anesthetic techniques in high-risk pediatric cardiac surgery.
- Maintaining hemodynamic stability through precise ventilator management and pharmacological support is crucial.
- Successful anesthetic management can lead to favorable short-term outcomes in complex CHD cases.
Abstract:
We report the anesthetic technique used for interatrial septal defect a 2-year-old girl weighing 11 Kg who presented with crossed atrioventricular connection (criss-cross heart), transposition of the great vessels, interatrial and interventricular septal defects, and subpulmonary and pulmonary valve stenoses. The patient was proposed for total cavopulmonary anastomosis with basal arterial oxygen saturation (SapO2) at 65%. Anesthesia was induced with inhaled agents and after intubation, hyperventilation was induced to achieve an end-tidal carbon dioxide pressure around 27 mm Hg. General anesthesia was provided in combination with spinal infusion of morphine chloride (100 microg Kg(-1)) for pain control. A Fontan procedure was carried out uneventfully with cardiopulmonary bypass. Milrinone was used at the extracorporeal circuit pump outlet. The patient was transferred to the pediatric intensive care unit where she was extubated without complications 90 minutes after admission. Anesthetic management is based on maintaining adequate preloading doses by administering volume, inhaled and/or intravenous agents, or use of vasoconstrictors and adjustment of ventilator parameters to modify pulmonary or systemic vascular resistance. We were able to maintain normal arterial pressure in our patient and provide adequate preloading through hyperventilation to reduce pulmonary vascular resistance.
