///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Successful Elective Dilation and Evacuation (D&E) in a Patient with Univentricular Heart with Fontan Palliation

Abstract Number: RF6AI-155
Abstract Type: Case Report Case Series

Nitish Gupta MD1 ; Yelena Spitzer MD2

Title:

Successful Elective Dilation and Evacuation (D&E) in a Patient with Univentricular Heart with Fontan Palliation

Case:

24 year old female with history of Tricuspid Atresia type II, Pulmonary Atresia and Transposition of the Great who underwent bilateral Blalock-Taussig shunt followed by Fontan procedure at 5 years of age was admitted for elective termination of pregnancy (D&E) at 21 weeks. Procedure was planned with multi-disciplinary approach between Anesthesiology, Cardiology, Maternal Fetal Medicine and Family Planning teams.

Due to coexisting history of Scoliosis with Harrington rods, neuraxial anesthesia was not preferred. After a pre-induction Arterial-line, she was intubated with Rapid Sequence Induction with 2mg Midazolam, 1 mcgs/kg Fentanyl, 0.3 mgs/Kg Etomidate and 1.5 mg/kg Succinylcholine. Patient was maintained on spontaneous breathing on 100% FiO2 without pressure support and anesthesia was maintained with 125-175 mcg/kg/min Propofol infusion, also requiring low dose phenylephrine infusion (10-20 mcgs/min). She received Infective endocarditis prophylaxis and oxytocin bolus. Procedure was uneventful and she was discharged to home on postoperative day 2.

Discussion:

Patients with Fontan physiology are largely preload dependent, hypovolemia, increases in Pulmonary Vascular Resistance (PVR) and depression of ventricular function should be avoided. Factors that increase PVR include inadequate analgesia or anesthesia, hypercarbia, acidosis, vasoactive drugs, and increased mean intrathoracic pressure.

Gradual titration of Epidural anesthesia or low dose spinal anesthesia after adequate fluid loading could be preferred as it will minimize changes in PVR and preserve cardiac function.

When proceeding with general anesthesia, induction agents that depress myocardial contractility should be avoided. High dose volatile anesthetic agents can increase the likelihood of arrhythmias.

An increase in oxygen requirements will be indicative of increasing right to left shunting through a fenestration or intrapulmonary shunts, due to a decrease in ventricular function, decreased pulmonary blood flow, or ventilation-perfusion inequalities. When controlled ventilation cannot be avoided, use of Low respiratory rates, short inspiratory times, low PEEP, and tidal volumes of 5–6 ml/kg will allow adequate pulmonary blood flow, normocarbia, and a low PVR.

When warranted, Transesophageal echocardiography, Esophageal Doppler device and/or Arterial line can be useful in assessing preload, ventricular function, cardiac output, responsiveness to fluid challenge, and allow repeated measurement of blood gases and continuous blood pressure monitoring.

Patients with Fontan physiology are predisposed to decreased functional status. As a large number of children are undergoing successful palliation for complex congenital heart defects, knowledge of managing such patients should be achieved to minimize morbidity in non-cardiac procedures.

SOAP 2019