Anesthetic implications of adults with congenital heart disease

In adults with congenital heart disease who are confronted with noncardiac surgery, perioperative risks can be reduced, often appreciably, when problems inherent to this patient population are anticipated. The first necessity is to clarify the diagnosis and to be certain that appropriate information is obtained from a cardiologist with adequate knowledge of congenital heart disease in adults. Physiology and anatomy can vary significantly among patients who superficially carry identical diagnoses and would seem to fit under the same rubric. Elective noncardiac surgery should be preceded by clinical cardiovascular assessment, including reviewing clinical and laboratory data and securing necessary diagnostic studies. Preoperative assessment should be performed far enough in advance of the anticipated surgery to allow for critical assessment of the data. Appropriate cardiovascular laboratory studies to be obtained or reviewed include electrocardiograms, chest radiographs, echocardiograms, and cardiac catheterization data (which may include specialized intracardiac electrophysiologic testing). Congenital heart disease in adults is a new and evolving area of special interest and expertise in cardiovascular medicine. Multidisciplinary centers for the care of these patients are being developed. The 22nd Bethesda Conference recommended that these centers include anesthesiologists with special expertise in managing patients with congenital heart disease among their consultants. These anesthesiologists can function either as attending anesthesiologists when patients require noncardiac surgery, or as consultants and resource individuals to other anesthesiologists. Adults with congenital heart disease may present with age-related acquired cardiovascular and noncardiovascular disorders in addition to postoperative cardiac residua and sequelae, all of which require meticulous preoperative planning and consultation before noncardiac surgery is performed. We recommend that, particularly in larger departments of anesthesiology, select members of the department serve as consultants to anesthesiologists and to other members of the medical staff for these cases, especially when large numbers of adults with congenital heart disease are to be treated.