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Anesthetic Management for a Patient with Congenitally Corrected Transposition of the Great Arteries
Abstract Number: T3C-1
Abstract Type: Case Report/Case Series
Congenitally corrected transposition of the great arteries (CCTGA), is a rare congenital heart disease, that accounts for less than 1% of congenital cardiac conditions.1 CCTGA is characterized by abnormal atrioventricular and ventricular-great artery discordance. The right atrium empties into the left ventricle (LV) and deoxygenated blood flows through the pulmonary artery (PA). The oxygenated blood empties from the left atrium into the right (systemic) ventricle (RV) and into the aorta.1
A 22-year-old G1PO at 38 4/7 with a past medical history significant for a diagnosis of CCTGA and related ventricular septal defect, was admitted in labor to our unit. Her CCTGA, was initially treated with a pulmonary artery (PA) banding procedure. Subsequently, she underwent takedown of the PA band, and closure of her atrial and ventricular septal defects. Her surgery was complicated by surgical complete atrioventricular block, which has required a pacemaker. Transthoracic echocardiogram findings revealed: 1) discordant atrioventricular and ventriculo-arterial connections. 2) Tricuspid (systemic valve)- unobstructed, with moderate regurgitation. 3) Mildly dilated systemic RV. 4) mild LVOT (sub-pulmonary) obstruction.(Figure 1)
An early epidural was placed at the L4-L5 level, aiming to reduce catecholamine release. After a test dose, the patient was bolused with 3 ml of 0.25% bupivacaine and 100 mcg hydromorphone. After assuring adequate analgesia and hemodynamic stability, a continuous epidural infusion was started at 8 mL/hr of 2mcg Fentanyl and 0.125% Bupivacaine solution. The patient delivered a 6 lbs 27 oz baby boy, after 6 hrs of labor. The patient had an uneventful delivery, and was discharged home 3 days later.
When caring for patients with CCTGA, one of the primary physiologic concerns is the systemic RV ability to endure the post-partum physiologic changes.2 The increased plasma volume and cardiac output may lead to congestive heart failure. In addition, arrhythmias, worsening cyanosis and cerebrovascular accidents have being described as possible complications during or after delivery.1,2 Intracardiac lesions/shunting, ventricular function and propensity for arrhythmias should be explored, and the anesthetic/analgesic plan should be tailored with those in mind. A multidisciplinary approach to patients with CCTGA is of utmost importance.
1. Anesth Analg 2008;107:1973-7.
2. J Clin Anesth 2001;13:517-20.