Pablo Motta

Perioperative management of pediatric patients on mechanical cardiac support

The population of children with end‐stage heart failure requiring mechanical circulatory support is growing. These children present for diagnostic imaging studies, various interventions and noncardiac surgical procedures that require anesthetic care. This article is a review of the population demographics of children on mechanical cardiac support, the alternative devices available, and the important concepts for safe perioperative management of these patients. The discussion will be limited to devices for short‐ and long‐term cardiac support, excluding extracorporeal membrane oxygenation (ECMO) for respiratory support.

Transesophageal echocardiography in tetralogy of Fallot.

Transesophageal echocardiography (TEE) plays an important role in the anatomical, functional, and hemodynamic assessment of patients with congenital heart disease (CHD). This imaging approach has been applied to both children and adults with a wide range of cardiovascular malformations. Extensive clinical experience documents significant contributions, particularly in the perioperative setting. In fact, in the current medical era, many consider this technology to be an essential adjunct to surgical and anesthetic management in CHD. This review focuses on the applications of TEE in patients with tetralogy of Fallot (TOF), the most common form of cyanotic heart disease. Emphasis is given to the perioperative use of this imaging modality and benefits derived during the prebypass and postbypass periods. Limitations and pitfalls relevant to the TEE assessment in patients with this anomaly are also addressed.

Anesthetic Considerations for Adults Undergoing Fontan Conversion Surgery

There are currently in North America more adults with congenital heart disease than children. This article discusses the anesthetic considerations in adults with single-ventricle physiology and prior repairs who present for Fontan conversion surgery as a demonstration of the challenges of caring for adults undergoing interventions for the repair of congenital heart defects. The care of these patients requires an understanding of the impact of passive pulmonary blood flow and single systemic ventricular physiology. The perioperative morbidity in this patient population remains high.

Cardiac Anesthesia in Infants and Children: Postoperative Bleeding and Coagulation Management

Postoperative bleeding is the most common complication after pediatric cardiac surgery. Up to 5 % of cardiac surgery will require re-exploration for major blood loss in the first 24 h after surgery. Uncontrolled bleeding if not addressed early could lead to hypovolemic shock, multi-organ failure, and eventually death. Concealed bleeding in the chest could also cause cardiac tamponade if the chest and mediastinum are not adequately drained. Blood product use is not devoid of complication, and strategies should be designed to minimize transfusion as much as possible. There are several known medical and surgical risk factors for postoperative bleeding. During the preoperative visit, the anesthesiologist should investigate for “red flags” for postoperative bleeding and address them. Unnecessary medications that could affect coagulation should be discontinued. Medical conditions that affected the coagulation system should be stabilized. Cardiopulmonary bypass (CPB) strategies and surgical plan should also consider the effect on bleeding and coagulation. Finally it is very important to plan for adequate intravenous access and use of prophylactic agents and to secure availability of blood, coagulation factors, and components.

Intraoperative Transesophageal Echocardiography in the Norwood-Sano Palliation of Hypoplastic Left Heart Syndrome.

May 2016 • Volume 122 • Number 5 www.anesthesia-analgesia.org 1301 We present the case of a 9-day-old, 3480-g infant with hypoplastic left heart syndrome (HLHS) undergoing Norwood-Sano surgical palliation. Attempts to contact the patient’s guardians were unsuccessful. Our IRB waived the need for consent for publication of this report. After uneventful induction of general anesthesia, a pediatric transesophageal echocardiography (TEE) probe was inserted (6.0–7.0 MHz, Vivid E9 ultrasound machine GE BT 11.1, GE Medical Systems, Waukesha, WI). Precardiopulmonary bypass (pre-CPB) imaging confirmed the diagnosis of HLHS (aortic atresia, severe mitral stenosis, hypoplastic left ventricle) and demonstrated a restrictive interatrial communication, competent tricuspid valve, and qualitatively normal right ventricular (RV) systolic function (Fig. 1; Supplemental Digital Content 1, Supplemental Video 1, http://links.lww.com/AA/B351). The main pulmonary artery (PA) was dilated with patent branches, and there was evidence of bidirectional shunting across the ductus arteriosus. The infant underwent a Norwood-Sano operation consisting of aortic reconstruction, atrial septectomy, and placement of a Sano shunt (RV to PA 5-mm Gore-Tex® graft, W.L. Gore & Associates, Inc., Flagstaff, AZ). TEE was used for intraoperative monitoring, to document adequate cardiac deairing, and for assessment of the surgical intervention. Post-CPB TEE demonstrated unrestrictive (left to right) atrial shunting, no tricuspid regurgitation, and fair RV systolic function (Figs. 2 and 3; Supplemental Digital Content 1, Supplemental Video 2, http://links.lww.com/AA/B352). There was no evidence of flow acceleration across the neoaortic outflow or neoaortic valve regurgitation. Filling of the native aorta and coronary vessels was documented. Interrogation of the Sano shunt showed the expected systolic–diastolic (“to and fro”) flow pattern by color Doppler and mild flow acceleration by spectral Doppler, with a peak shunt velocity of 3 m/s. After initial weaning from CPB, the infant became acutely hemodynamic unstable (hypotensive and bradycardic: 60/30 mm Hg/135 bpm relative to baseline values: 80/40 mm Hg/150 bpm), likely related to surgical manipulation. TEE demonstrated decreased RV contractility manifested by abnormal free-wall motion and a qualitative decreased color Doppler flow signal in the native aortic root. After adjusting the inotropic/vasoactive strategy and optimizing the hematocrit (increased from 35% to 45%), the hemodynamics improved in association with increased myocardial contractility and an enhanced color flow Doppler signal in the native aorta (Supplemental Digital Content 1, Supplemental Video 3, http://links.lww.com/AA/B353).

Anesthesia for Cardiac Surgery in Neonates

Cardiac surgery in the neonate usually is indicated for treatment of congenital malformations of the heart or cardiovascular system. Extremely rare is the need for surgical intervention for pathologies such as endocarditis, cardiac tumors, rhythm disturbances, or pericardial disease. Thus, the focus of this chapter is on anesthesia for cardiac surgery in the neonate with congenital heart disease (CHD). This chapter begins with a brief overview of the cardiovascular physiology of the fetus and neonate, followed by a discussion of CHD that includes the epidemiology, clinical features, and diagnosis in the neonate. Selected anomalies of particular relevance in this age group are reviewed, with emphasis on anatomic features, pathophysiology of the defect, perioperative management, and specific considerations during anesthetic care. This is followed with an in-depth discussion on the important aspects of anesthetic practice in the neonate with CHD undergoing cardiac surgery. Finally, several specific perioperative problems and concerns in the neonate are highlighted.

The role of echocardiography in the management of an embolized atrial septal Helex occluder.

A 6-year-old boy with a secundum atrial septal defect (ASD) presented for percutaneous closure. The patient’s parents consented to publication of this report. Transthoracic echocardiography revealed an atrial septum length of 35 mm, enlarged right atrium, right ventricle (RV) dilation with normal systolic function, and trivial tricuspid valve insufficiency. Under general anesthesia, cardiac catheterization demonstrated a pulmonary/systemic flow ratio of 2.8. An intracardiac echocardiographic (ICE) examination showed the resting diameter of the ASD in the longitudinal plane to measure 15 mm. A sizing balloon measured the length of the ASD to be 23 mm by ICE examination. A 35-mm Helex occluder device (W.L. Gore and Associates, Flagstaff, AZ) was used for closure. The Helex appeared to be well configured by ICE examination, but the upper portion of the right atrial disk protruded into the right atrium without evidence of a residual leak or flow obstruction. Transthoracic echocardiography showed no distortion of atrioventricular valves’ motion. The positioning had not changed after emergence from anesthesia. Twelve hours after closure, the patient experienced chest pain and desaturation (mid-80s), while remaining hemodynamically stable. A transthoracic echocardiography showed the Helex in the main pulmonary artery (PA) straddling into the right PA (Fig. 1, A and B). The RV was moderately dilated with normal systolic function. There was mild tricuspid valve insufficiency with maximal velocity of 3.3 m/s, and RV pressure was estimated by the modified Bernoulli equation to be 54 mm Hg. There was trivial pulmonic valve regurgitation. The patient was taken urgently to the operating room where he underwent extraction of the Helex and suture closure of his ASD. Intraoperative transesophageal echocardiography (TEE) confirmed an ASD (Fig. 2) and the location of the Helex in the right PA at 1.69 cm distal to the pulmonic valve (amenable of surgical retrieval via the atriotomy) (Figure 3A; Video 1, http://links.lww.com/AA/A48). The pulmonic valve function was preserved with trivial regurgitation, but the continuous wave Doppler in the right PA demonstrated a velocity of 2.2 m/s and a peak gradient of 19.4 mm Hg (Figure 3B; Video 2, http://links.lww.com/AA/A49). Postcardiopulmonary bypass TEE demonstrated normal cardiac function, no residual ASD, trivial tricuspid valve insufficiency, and trivial pulmonic valve insufficiency.