Transcatheter closure of ventricular septal defects: hemodynamic instability and anesthetic management

The technique of transcatheter ventricular septal defect (VSD) device closure may be associated with significant hemodynamic instability. The anesthetic records and catheterization data of 70 consecutive transcatheter VSD closures between February 1989 and September 1992 were reviewed, and risk factors associated with hemodynamic instability evaluated. In 28 of 70 procedures (40%), hypotension (> 20% decrease in systolic blood pressure from baseline) occurred; 12 responded to administration of fluids intravascularly alone, whereas 16 patients required additional acute resuscitation. Significant dysrhythmias occurred during 20 (28.5%) anesthetics associated with hypotension and requiring treatment or catheter withdrawal. ASA physical status, precatheterization indication for device placement, and patient size were not predictive of hemodynamic instability during the procedure. Blood transfusions were necessary in 38 (54.4%) cases and were size-related, with patients weighing less than 10 kg requiring a significantly larger transfusion volume (25.1 +/- 12.4 mL/kg). After 35 procedures (50%) patients were admitted directly to the intensive care unit (ICU) due primarily to hemodynamic instability or procedure duration; 24 (68%) required mechanical ventilation. No deaths occurred; there was no late morbidity due to catheterization-related events. Intravenous sedation was used for the initial catheterizations, maintained with a combination of midazolam, ketamine, and morphine. Subsequently general intravenous or inhaled anesthesia was predominantly used during transesophageal echocardiography and internal jugular vein cannulation. We conclude that hemodynamic instability is common during device closure of VSDs, and is likely to be an inescapable feature of these procedures in many patients because of the technique necessary for device placement.