Anesthesia for adults with congenital heart disease undergoing noncardiac surgery
- Edmund Jooste, MB, ChB
Edmund Jooste, MB, ChB
- Associate Professor of Anesthesiology and Pediatrics
- Duke Children's Hospital
- Kelly Machovec, MD, MPH
Kelly Machovec, MD, MPH
- Assistant Professor of Anesthesiology and Pediatrics
- Duke University School of Medicine
- Section Editors
- Jonathan B Mark, MD
Jonathan B Mark, MD
- Section Editor — Cardiac Anesthesia
- Professor of Anesthesiology
- Duke University Medical Center
- Chief, Anesthesiology Service
- Veterans Affairs Medical Center
- Lena S Sun, MD
Lena S Sun, MD
- Editor-in-Chief — Anesthesiology
- Section Editor — Pediatric/Neonatal Anesthesia
- Professor of Anesthesiology and Pediatrics
- Columbia University Medical Center
- Heidi M Connolly, MD, FASE
Heidi M Connolly, MD, FASE
- Section Editor — Congenital Heart Disease
- Professor of Medicine
- Mayo Medical School
Congenital heart disease (CHD) is present in approximately 6 to 19 of 1000 live births . In the United States, approximately 1,000,000 pediatric and adult patients have CHD, with a growing number surviving into middle age and beyond [1,2]. Many of these patients require anesthetic care for either cardiac or noncardiac surgery. The anesthesiologist should understand the patient's native CHD lesion and prior palliation or repair, current cardiopulmonary reserve, and potential adverse effects of the planned surgical procedure in order to assess risk and develop an anesthetic plan appropriate for lesion-specific hemodynamic goals.
This topic will discuss the anesthetic management of adult CHD patients undergoing noncardiac surgery. Anesthetic management during labor and delivery for women with congenital and other high-risk heart disease is discussed separately. (See "Anesthesia for labor and delivery in high-risk heart disease: General considerations" and "Anesthesia for labor and delivery in high-risk heart disease: Specific lesions".)
The history focuses on the native congenital heart disease (CHD) lesion, prior palliative or reparative procedures, and current functional status (eg, exercise tolerance and symptoms of heart failure). The physical examination focuses on signs of cyanosis or heart failure.
Also noted are noncardiac sequelae of CHD such as developmental delay and disability, or presence of an associated genetic syndrome (eg, Down or Williams syndrome).
High- and moderate-risk lesions — CHD patients with high and moderate risk are ideally managed at a center with expertise in the care of adult patients with CHD, particularly if a major surgical procedure is planned . Such patients may require advanced monitoring and other specialized management during the procedure. (See 'Monitoring' below and 'Anesthetic management' below.)
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- PREANESTHETIC ASSESSMENT
- High- and moderate-risk lesions
- Hemodynamic goals for specific lesions
- - Right-to-left shunt with cyanosis
- - Left-to-right shunt with pulmonary overcirculation
- - Fontan physiology (cavopulmonary palliation)
- - Pulmonary arterial hypertension
- - Obstructive lesions
- - Regurgitant lesions
- - Presence of ventricular dysfunction
- - Cardiac transplantation
- Prior cardiac surgery or intervention
- Noncardiac sequelae
- PREANESTHETIC MANAGEMENT
- Chronically administered medications
- ANESTHETIC MANAGEMENT
- Precautions to avoid air embolism
- Endocarditis prophylaxis
- Arrhythmia risk management
- Choice of induction agent
- Emergence and extubation
- Other considerations
- - Neuraxial anesthesia and analgesia
- - Fluid management
- - Vasoactive drugs
- - Ventilatory support
- - Treatment of arrhythmias
- - Laparoscopic surgery
- POSTOPERATIVE MANAGEMENT
- SUMMARY AND RECOMMENDATIONS