Posterior fossa surgery in postshunt endocarditis patients: some anesthetic issues

A patient with an intracranial fourth ventricular cyst developed right heart endocarditis from an infected ventriculoatrial shunt inserted previously. Investigation revealed pneumonic involvement of the right lung, moderate tricuspid regurgitation, mild pulmonary artery hypertension, and a large right atrial vegetation. The shunt was removed and treatment of endocarditis started, before undertaking excision of the cyst under general anesthesia. During the operation there was a sudden deterioration in the patient's condition rapidly leading to death. Clinical features suggested intraoperative pulmonary embolism; both venous air embolism and a dislodged atrial vegetation were considered. However, in the absence of specific monitoring equipment and autopsy, the actual cause could not be ascertained. This clinical report highlights the anesthetic problems related to posterior fossa surgery in patients with right-sided endocarditis and suggests some possible management strategies.