Carotid approach to anterior circulation thromboembolectomy in an adult with failing fontan physiology: a case report

Abstract Background Anesthetic management of an adult with failing Fontan physiology is complicated given inherent anatomical and physiological alterations. Neurosurgical interventions including thromboembolectomy may be particularly challenging given importance of blood pressure control and cerebral perfusion. Case Presentation We describe a 29 year old patient born with double outlet right ventricle (DORV) with mitral valve atresia who after multi-staged surgeries earlier in life, presented with failing Fontan physiology. She was admitted to the hospital almost 29 years after her initial surgeries to undergo workup for a dual heart and liver transplant in the context of a failing Fontan with elevated end diastolic pressures, NYHA III heart failure symptoms, and liver cirrhosis from congestive hepatopathy. During the workup in the context of holding anticoagulation for invasive procedures, she developed a middle cerebral artery (MCA) stroke requiring a thromboembolectomy via left carotid artery approach. Discussion and Conclusions This case posed many challenges to the anesthesiologist including airway control, hemodynamic and cardiopulmonary monitoring, evaluation of perfusion, vascular access, and management of anticoagulation in an adult patient in heart and liver failure with Fontan physiology undergoing thromboembolectomy for MCA embolic stroke.

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Anesthetic Management of a Child From the Qinghai-tibet Plateau With a Double Outlet Right Ventricle and Severe Polycythemia: A Case Report

10.21203/rs.3.rs-47461/v1 ◽

2020 ◽

Author(s):

Lingcan Tan ◽

Weiyi Zhang ◽

Yiding Zuo ◽

Hongyang Chen ◽

Chunling Jiang

Keyword(s):

Right Ventricle ◽

Perioperative Management ◽

Perioperative Complications ◽

Anesthetic Management ◽

Double Outlet Right Ventricle ◽

Tibet Plateau ◽

Low Oxygen ◽

Case Presentation ◽

Fontan Surgery ◽

Qinghai Tibet Plateau

Abstract Background Acquired secondary polycythemia is common in patients with a double outlet right ventricle, and results from tissue hypoxia. Secondary erythrocytosis can cause coagulation deficiencies, and increases the risks of thrombosis and infarction. Perioperative management in double outlet right ventricle patients with severe erythrocytosis is intractable, and only a few cases have been reported. Case presentation: Herein, we report the anesthetic management of a 10-year-old female patient with a double outlet right ventricle. She lived in the low-oxygen Qinghai−Tibet Plateau, and presented with severe polycythemia (hemoglobin, 24.8 g/dL; hematocrit, 75%). She underwent a modified Fontan surgery, which was satisfactory and without any perioperative complications. Our anesthetic management highlights the importance of perioperative hemodilution to decrease the risk of thromboembolism, and correction of coagulopathy to prevent hemorrhage. Conclusions Anesthetic management is challenging in rare cyanotic congenital heart disease patients with severe polycythemia. For prevention of thrombosis and hemorrhage, it is important to adopt perioperative hemodilution and correction of coagulopathy.

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Remimazolam anesthesia for cardiac surgery with cardiopulmonary bypass: a case report

JA Clinical Reports ◽

10.1186/s40981-021-00424-0 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Kota Saito ◽

Sho Ohno ◽

Makishi Maeda ◽

Naoyuki Hirata ◽

Michiaki Yamakage

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Oxygen Saturation ◽

Anesthetic Management ◽

Perioperative Period ◽

Maze Procedure ◽

Intraoperative Awareness ◽

Case Presentation ◽

Venous Oxygen Saturation ◽

Index Value

Abstract Background Remimazolam has less cardiovascular depressant effects than propofol in non-cardiac surgical patients. However, the efficacy and safety of remimazolam in cardiac surgery with cardiopulmonary bypass (CPB) have not been reported. We present a case of successful anesthetic management using remimazolam in cardiac surgery with CPB. Case presentation A 76-year-old female was scheduled for mitral valve repair, tricuspid annuloplasty, maze procedure, and left atrial appendage closure. We used remimazolam in induction (6.0 mg/kg/h) and maintenance (0.6–1.0 mg/kg/h) of general anesthesia, and the bispectral index value was maintained in the range of 36 to 48 including the period of CPB. Hemodynamics, mixed venous oxygen saturation, and bilateral regional cerebral oxygen saturation were maintained within acceptable ranges. There was no intraoperative awareness/recall or serious complications associated with remimazolam throughout the perioperative period. Conclusions Remimazolam can be used the same as other existing anesthetics in cardiac surgery with CPB.

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Intravascular Mechanical Cavopulmonary Assistance for Patients With Failing Fontan Physiology

Artificial Organs ◽

10.1111/j.1525-1594.2009.00940.x ◽

2009 ◽

Vol 33 (11) ◽

pp. 977-987 ◽

Cited By ~ 32

Author(s):

Sonya S. Bhavsar ◽

Jugal Y. Kapadia ◽

Steven G. Chopski ◽

Amy L. Throckmorton

Keyword(s):

Fontan Physiology ◽

Failing Fontan

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Rebuttal

Cardiology in the Young ◽

10.1017/s1047951104006432 ◽

2004 ◽

Vol 14 (S1) ◽

pp. 114-114 ◽

Cited By ~ 1

Author(s):

Leonard L. Bailey

Keyword(s):

Coronary Disease ◽

Reconstructive Surgery ◽

Fontan Circulation ◽

Actuarial Survival ◽

Term Survival ◽

Long Term Survival ◽

Fontan Physiology ◽

Failing Fontan

The portrayal of a beautiful youngster performing uninhibited acrobatics based on Fontan physiology, as presented by Marshall Jacobs, is a brilliant and beautiful thing for us to see. It is, perhaps, all about will over physiology. But it is, nevertheless, happening for that child. Marshall mentioned the need for re-transplantation, whether the beginning strategy was transplantation or reconstructive surgery. Indeed, a relatively small percentage of children transplanted will require re-transplantation because of severe graft coronary disease. Remarkably, in the Loma Linda experience, 10-year actuarial survival for 26 patients following elective re-transplantation is over 85%, exceeding overall actuarial survival at 10 years for children following primary transplantation. Many of the transplanted infants, however, seem to be realistically hopeful that one heart will last their entire lifetime. Of course, the hope is that their's will be a long and healthy lifetime. The requirement for late transplantation following Fontan procedures, however, seems almost inevitable. We'll simply have to keep these children with Fontan circulation under surveillance to see when, in the course of their lives, transplantation will become necessary. Unfortunately, operative and long-term survival among children who are transplanted for failing Fontan physiology have, as yet, been somewhat suboptimal.

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Abstract 14773: Biventricular Conversion After Fontan Completion: A Preliminary Experience

Circulation ◽

10.1161/circ.142.suppl_3.14773 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Ilias P Doulamis ◽

Supreet P Marathe ◽

Breanna L Piekarski ◽

Rebecca S Beroukhim ◽

Gerald R Marx ◽

...

Keyword(s):

Fontan Circulation ◽

Exercise Intolerance ◽

Optimal Timing ◽

Atrioventricular Canal ◽

Protein Losing Enteropathy ◽

Systolic Volume ◽

Hepatic Congestion ◽

Atrioventricular Canal Defect ◽

Fontan Physiology ◽

Failing Fontan

Hypothesis: Biventricular conversion (BiVC) following takedown of Fontan circulation is feasible and results in improved hemodynamics. Methods: Retrospective analysis of patients who had takedown of Fontan circulation and conversion to BiV circulation at a single center from September 2007 to April 2020. Failing Fontan physiology was defined as Fontan circulation pressure >15 mmHg. Results: There were 23 patients (median age: 10.0 (7.5-13.0) years); 15 (65%) had failing Fontan physiology and 8 (35%) underwent elective takedown of their Fontan circulation. Of the 15 patients with failing Fontan physiology, 4 had exercise intolerance or cyanosis, 3 had hepatic congestion or cirrhosis, 3 had end-organ damage and 1 patient had protein losing enteropathy; the rest 4 patients had no other sign of SVP complications. A subset of patients (n=6) underwent recruitment of the non-dominant ventricle prior to conversion. HLHS (p<0.01) and sub-/aortic stenosis (p<0.01) were more common in these patients. BiVC with or without staged ventricular recruitment led to a significant increase in indexed end-diastolic volume (p<0.01), indexed end-systolic volume (p<0.01) and ventricular mass (p<0.01) of the non-dominant ventricle (14 RV, 9 LV). There were 1 (4%) early and 4 (17%) late deaths. All who underwent elective BiVC survived, while 2-year survival rate for patients with a failing Fontan circulation was 72.7% (95% CI: 37-90%) (Figure 1). The overall, 1-year reintervention free survival was 44.1% (95% CI: 21-65%). Left dominant atrioventricular canal defect (p<0.01) and early year of BiVC (p=0.02) were significant predictors for mortality. Conclusions: BiVC is feasible in patients with failing Fontans, and has promising outcomes after elective takedown of Fontan circulation. A staged approach for ventricular recruitment does not seem inferior to primary BiVC. The optimal timing for BiVC in Fontan patients needs further evaluation.

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Hypotension during endovascular treatment under general anesthesia for acute ischemic stroke

PLoS ONE ◽

10.1371/journal.pone.0249093 ◽

2021 ◽

Vol 16 (6) ◽

pp. e0249093

Author(s):

Sabine L. Collette ◽

Maarten Uyttenboogaart ◽

Noor Samuels ◽

Irene C. van der Schaaf ◽

H. Bart van der Worp ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

General Anesthesia ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Randomized Clinical Trials ◽

Anesthetic Management ◽

Poor Functional Outcome ◽

Anterior Circulation ◽

Period Increase

Objective The effect of anesthetic management (general anesthesia [GA], conscious sedation, or local anesthesia) on functional outcome and the role of blood pressure management during endovascular treatment (EVT) for acute ischemic stroke is under debate. We aimed to determine whether hypotension during EVT under GA is associated with functional outcome at 90 days. Methods We retrospectively collected data from patients with a proximal intracranial occlusion of the anterior circulation treated with EVT under GA. The primary outcome was the distribution on the modified Rankin Scale at 90 days. Hypotension was defined using two thresholds: a mean arterial pressure (MAP) of 70 mm Hg and a MAP 30% below baseline MAP. To quantify the extent and duration of hypotension, the area under the threshold (AUT) was calculated using both thresholds. Results Of the 366 patients included, procedural hypotension was observed in approximately half of them. The occurrence of hypotension was associated with poor functional outcome (MAP <70 mm Hg: adjusted common odds ratio [acOR], 0.57; 95% confidence interval [CI], 0.35–0.94; MAP decrease ≥30%: acOR, 0.76; 95% CI, 0.48–1.21). In addition, an association was found between the number of hypotensive periods and poor functional outcome (MAP <70 mm Hg: acOR, 0.85 per period increase; 95% CI, 0.73–0.99; MAP decrease ≥30%: acOR, 0.90 per period; 95% CI, 0.78–1.04). No association existed between AUT and functional outcome (MAP <70 mm Hg: acOR, 1.000 per 10 mm Hg*min increase; 95% CI, 0.998–1.001; MAP decrease ≥30%: acOR, 1.000 per 10 mm Hg*min; 95% CI, 0.999–1.000). Conclusions Occurrence of procedural hypotension and an increase in number of procedural hypotensive periods were associated with poor functional outcome, whereas the extent and duration of hypotension were not. Randomized clinical trials are needed to confirm our hypothesis that hypotension during EVT under GA has detrimental effects.

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MACITENTAN USE AS SERIAL THERAPY IN FAILING FONTAN PHYSIOLOGY

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(17)34021-4 ◽

2017 ◽

Vol 69 (11) ◽

pp. 632

Author(s):

Tabitha Grace Moe

Keyword(s):

Fontan Physiology ◽

Failing Fontan

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Repeated Anesthetic Management for a Patient With Klippel-Feil Syndrome

Anesthesia Progress ◽

10.2344/0003-3006-61.3.103 ◽

2014 ◽

Vol 61 (3) ◽

pp. 103-106 ◽

Cited By ~ 4

Author(s):

Yuri Hase ◽

Nobuhito Kamekura ◽

Toshiaki Fujisawa ◽

Kazuaki Fukushima

Keyword(s):

Airway Management ◽

Cervical Vertebrae ◽

Anesthetic Management ◽

Preoperative Evaluation ◽

Fatal Outcome ◽

Laryngeal Edema ◽

Airway Control ◽

First Choice ◽

Surgical Airway ◽

Preoperative Examination

Abstract Klippel-Feil syndrome (KFS) is a rare disease characterized by a classic triad comprising a short neck, a low posterior hairline, and restricted motion of the neck due to fused cervical vertebrae. We report repeated anesthetic management for orthognathic surgeries for a KFS patient with micrognathia. Because KFS can be associated with a number of other anomalies, we therefore performed a careful preoperative evaluation to exclude them. The patient had an extremely small mandible, significant retrognathia, and severe limitation of cervical mobility due to cervical vertebral fusion. As difficult intubation was predicted, awake nasal endotracheal intubation with a fiberoptic bronchoscope was our first choice for gaining control of the patient's airway. Moreover, the possibility of respiratory distress due to postoperative laryngeal edema was considered because of the surgeries on the mandible. In the operating room, tracheotomy equipment was always kept ready if a perioperative surgical airway control was required. Three orthognathic surgeries and their associated anesthetics were completed without a fatal outcome, although once the patient was transferred to the intensive care unit for precautionary postoperative airway management and observation. Careful preoperative examination and preparation for difficult airway management are important for KFS patients with micrognathia.

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