The Pediatric Cardiac Anesthesia Handbook

Preface xvii Part I The Basics 1 1 Cardiovascular Development 3 Embryology 3 Cardiovascular Physiology 3 Fetal Circulation 3 Closure of the Ductus Arteriosus 5 Closure of the Foramen Ovale 6 Closure of the Ductus Venosus 6 Pulmonary Vascular Changes 6 Myocardial Performance in the Neonate 7 Hemodynamic Changes at Birth 7 2 Important Concepts in Congenital Heart Disease 9 Pathophysiology of CHD 9 Concepts of Shunting, Single‐Ventricle Physiology, and Inter‐Circulatory Mixing 9 Shunting 9 Effective Blood Flow 10 Total Pulmonary Blood Flow/Total Systemic Blood Flow 10 Single‐Ventricle Physiology 10 Intercirculatory Mixing 13 Classification of Anatomic Shunts 15 Simple Shunts 15 Complex Shunts 15 Pulmonary Vascular Pathophysiology 18 Causes of Pre‐Capillary PH in CHD 18 Causes of Post‐Capillary PH in CHD 18 Control of Pulmonary Vascular Resistance 19 PaO2 19 PaCO2 19 pH 19 Variation in Lung Volumes 19 Vasodilator Agents 20 Sympathetic Nervous System Stimulation 20 Myocardial Ischemia 21 Aortic Diastolic Pressure 21 Subendocardial Pressure 21 Heart Rate 22 Anatomic Coronary Artery Lesions 22 3 Preoperative Evaluation 23 Clinical History 23 Physical Examination 23 Associated Congenital Abnormalities 24 Laboratory Data 25 Pregnancy 26 Psychological Considerations 26 Preoperative Preparation 27 Preoperative Fluid Therapy 27 Preoperative Medications 29 4 Intraoperative Management 31 Intraoperative Monitoring 31 ECG and Blood Pressure 31 Systemic Oxygen Saturation 32 End‐Tidal CO2 32 Central Venous Pressure 32 Temperature 33 Near‐Infra‐Red Spectroscopy 33 Transcranial Doppler 34 Transesophageal Echocardiography (TEE) 35 Airway Management 35 Anesthesia Induction and Maintenance 36 Induction of Anesthesia 36 Mask Induction 36 Intravenous Induction 36 Maintenance of Anesthesia 37 5 Interpretation of Cardiac Catheterization Data 39 Right‐Heart Catheterization 39 Right Atrial Pressure (RAP) Waveform 39 Right Ventricular Pressure (RVP) Waveform 39 Pulmonary Artery Pressure (PAP) Waveform 40 Left‐Heart Catheterization 40 Left Atrial Pressure (LAP) Waveform 41 Left Ventricular Pressure (LVP) Waveform 41 Aortic Pressure Waveform 41 Left Ventriculography 41 Coronary Angiography 43 Coronary Anatomy 43 Anatomic Coronary Lesions 44 Coronary Collaterals 45 Cardiac Output Determination 45 Thermodilution Technique 45 Fick Determination 45 Evaluation of Cardiac Shunts 46 Shunt Location 46 Shunt Quantification 46 Saturation Data 48 Resistances 48 Assessment of Pulmonary Vascular Anatomy 48 Evaluation of the Pulmonary Vasculature 48 Pulmonary Artery Wedge Angiogram 48 Pulmonary Vein Wedge Angiogram 49 Assessment of Pulmonary Arterial Hypertension 49 Assessment of Valve Lesions 50 Stenotic Lesions 50 Regurgitant Lesions 50 6 Cardiopulmonary Bypass 51 The Cardiopulmonary Bypass Circuit 51 Differences Between Adult and Pediatric CPB 53 CPB Flow Rates 53 Anesthesia During CPB 53 Monitoring During CPB 54 Hemodilution 54 Priming Solution 54 Ultrafiltration 55 Conventional Ultrafiltration 55 Modified Ultrafiltration 55 Blood Gas Management 55 Deep Hypothermic Circulatory Arrest and Regional Perfusion Techniques 57 Anticoagulation 57 Protamine Reversal 58 7 Mechanical Support Devices 59 Extracorporeal Membrane Oxygenation (ECMO) 59 Indications 59 Relative Contraindications 59 Modes of ECMO Support 59 Veno‐Venous (VV)‐ECMO 59 Veno‐Arterial (VA)‐ECMO 59 Device and Patient Complications 60 Common Terminology Used During an ECMO Run 61 Intraoperative Considerations for Patients on ECMO 61 Ventricular Assist Devices (VADs) 62 Indications 62 Relative Contraindications 62 Modes of VADs 62 Complications 62 Anesthetic Considerations for Patients Receiving VAD 62 Induction of Anesthesia and Pre‐Bypass Management 64 Post‐VAD Placement Management 65 BiVAD Insertion 65 Part II Specific Lesions 67 8 Patent Ductus Arteriosus 69 Introduction 69 Anatomy 69 Physiology 69 Surgical Therapy 69 Catheterization Laboratory Intervention 70 Anesthetic Management 70 Induction and Maintenance 70 Non‐Cardiac Surgery 71 9 Aortopulmonary Window 73 Introduction 73 Anatomy 73 Physiology 73 Surgical Management 73 Catheterization Laboratory Intervention 74 Anesthetic Management 75 Non‐Cardiac Surgery 75 10 Coarctation of the Aorta 77 Introduction 77 Anatomy 77 Physiology 77 Surgical Therapy 80 Catheterization Laboratory Intervention 80 Anesthetic Management 81 Induction and Maintenance 81 Management after Cross‐Clamp Removal 82 Non‐Cardiac Surgery 82 11 Atrial Septal Defect 83 Introduction 83 Anatomy 83 Ostium Secundum ASD 83 Ostium Primum ASD 83 Sinus Venosus Defects 84 Coronary Sinus Defect 84 Physiology 85 Surgical Therapy 85 Catheterization Laboratory Intervention 85 Anesthetic Management 86 Induction and Maintenance 86 Post‐CPB Management 86 Non‐Cardiac Surgery 87 12 Ventricular Septal Defect 89 Introduction 89 Anatomy 89 Subpulmonary or Supracristal Defects 89 Membranous or Perimembranous Defects 89 Conoventricular Defects 89 Inlet or Canal‐Type Defects 89 Muscular Defects 89 Physiology 89 Surgical Therapy 91 Catheterization Laboratory Intervention 91 Anesthetic Management 91 Induction and Maintenance 91 Post‐CPB Management 91 Non‐Cardiac Surgery 92 13 Atrioventricular Canal Defects 93 Introduction 93 Anatomy 93 Partial AVC 93 Transitional AVC 93 Complete AVC (CAVC) 93 Unbalanced AVC 94 Physiology 94 Surgical Therapy 95 Anesthetic Management 95 Induction and Maintenance 95 Post‐CPB Management 96 Non‐Cardiac Surgery 96 14 Double Outlet Right Ventricle 97 Introduction 97 Anatomy 97 Physiology 99 Surgical Therapy 100 Anesthetic Management 101 Induction and Maintenance 101 Post‐CPB Management 101 15 Truncus Arteriosus 103 Introduction 103 Anatomy 103 Physiology 104 Surgical Therapy 104 Catheterization Laboratory Intervention 105 Anesthetic Management 105 Goals 105 Induction and Maintenance 105 Post‐CPB Management 105 Goals 106 16 Total Anomalous Pulmonary Venous Return 107 Introduction 107 Anatomy 107 Physiology 108 Surgical Therapy 109 Anesthetic Management 109 Goals 109 Induction and Maintenance 110 Post‐CBP Management 110 Goals 110 Long‐Term Outcomes 110 17 Left Ventricular Outflow Tract Obstruction 113 Introduction 113 Anatomy 113 Physiology 113 Surgical Therapy 114 Catheterization Laboratory Intervention 114 Anesthetic Management 114 Goals 114 Induction and Maintenance 115 Post‐CPB Management 115 18 Mitral Valve 117 Mitral Valve Stenosis 117 Introduction 117 Anatomy 117 Physiology 118 Surgical Therapy 118 Catheterization Laboratory Intervention 118 Anesthetic Management 118 Goals 118 Pre‐Induction 119 Induction and Maintenance 119 Post‐Cardiopulmonary Bypass (CPB) Management 120 Mitral Valve Regurgitation 121 Introduction 121 Anatomy 121 Physiology 121 Surgical Management 122 Catheterization Laboratory Intervention 122 Anesthetic Management in Mitral Regurgitation 122 Goals 122 Premedication 122 Induction and Maintenance 122 Post‐CPB Management 123 19 Pulmonary Atresia/Intact Ventricular Septum (PA/IVS) 125 Introduction 125 Anatomy 125 Physiology 125 Surgical and Catheter‐Based Therapy 126 Anesthetic Management 129 Goals 129 Post‐CPB Management 129 20 Tetralogy of Fallot (TOF) 131 Introduction 131 Anatomy 131 Physiology 131 Hypoxic or Hypercyanotic Episodes (‘Tet Spells’) 132 Surgical Therapy 134 Palliative Shunts 134 Definitive Repair 136 Catheterization Laboratory Intervention 136 Anesthetic Management 137 Goals 137 Induction and Maintenance 137 Post‐CPB Management 138 Goals 138 Postoperative Junctional Ectopic Tachycardia 139 Non‐Cardiac Surgery 139 21 Tetralogy of Fallot with Pulmonary Atresia (TOF/PA) 141 Anatomy 141 Physiology 141 Surgical Therapy 141 Anesthetic Management 143 Post‐CPB Management 143 22 Tetralogy of Fallot with Absent Pulmonary Valve (TOF/APV) 145 Anatomy 145 Physiology 145 Surgical Therapy 146 Anesthetic Management 146 Post‐CPB Management 146 23 Transposition of the Great Arteries (TGA) 147 Introduction 147 Anatomy 147 Physiology 148 Surgical Therapy 151 Anatomic Repair or the Arterial (Jatene) Switch Procedure 151 Intra‐Atrial Physiologic Repair: Mustard and Senning Procedures 153 Rastelli, Lecompte, and Nikaidoh Procedures 154 Anesthetic Management 155 Goals 155 Induction and Maintenance 155 Post‐CPB Management 155 Goals 155 Non‐Cardiac Surgery 157 Congenitally Corrected Transposition of the Great Vessels 157 Introduction 157 Anatomy 157 Physiology 158 Surgical Management 158 Traditional Repair for C‐TGV 158 Double Switch Procedure and Atrial Switch‐Rastelli Procedures 158 24 Single‐Ventricle Lesions 161 Introduction 161 Physiology and Initial Procedures 161 Initial Procedures to Optimize Pulmonary Arterial Blood Flow 161 Initial Procedures to Optimize Pulmonary Venous Blood Flow 163 Initial Procedures to Optimize Systemic Blood Flow 163 Management of Single‐Ventricle Physiology 164 Anesthetic Management, Pre‐Initial Repair 166 Goals 166 Induction and Maintenance 167 Post‐CPB Management, Post‐Initial Repair 167 Goals 167 Single‐Ventricle Pathway, Superior Cavopulmonary Shunt or Bidirectional Glenn (BDG) 169 Anesthetic Management, Pre‐Superior Cavopulmonary Shunt 171 Goals 171 Induction and Maintenance 171 Post‐CPB Management, Post‐Superior Cavopulmonary Shunt 171 Goals 171 Definitive Repair: The Fontan Procedure or Total Cavopulmonary Connection (TCPC) 172 Fontan Physiology 172 Fenestrated Fontan 176 Anesthetic Management, Pre‐Fontan 176 Goals 176 Induction and Maintenance 177 Post‐CPB Management, Post‐Fontan Procedure 177 Goals 177 Non‐Cardiac Surgery 180 25 Hypoplastic Left Heart Syndrome 181 Introduction 181 Anatomy 181 Physiology 181 Surgical Therapy 182 Anesthetic Management 183 Goals 183 Post‐CPB Management 183 Biventricular Repair 184 The ‘Borderline’ Left Heart 184 The Left Heart Rehabilitation 184 Staged Left Ventricular Recruitment 184 Biventricular Conversion 185 Non‐Cardiac Surgery 185 26 Interrupted Aortic Arch 187 Introduction 187 Anatomy 187 Physiology 187 Surgical Management 189 Catheterization Laboratory Intervention 189 Anesthetic Management 190 Goals 190 Induction and Maintenance 190 Post‐CPB Management 190 Goals 190 27 Vascular Rings 191 Introduction 191 Anatomy 191 Physiology 191 Surgical Management 191 Catheterization Laboratory Intervention 192 Anesthetic Management 192 28 Tricuspid Atresia 195 Introduction 195 Anatomy 195 Physiology 195 Surgical Therapy 197 Anesthetic Management 197 Goals 197 29 Heart Transplantation 199 The Donor 199 Anesthetic Management of the Recipient 202 Preoperative Evaluation 202 Physical Examination 202 Premedication 202 Preinduction 202 Induction and Maintenance 203 Operative Procedure 205 Post‐CPB Management 207 Goals 207 Preparation for Termination of CPB 207 Impaired Systolic Function 207 Right Ventricular Afterload Mismatch 208 Sinus and Atrioventricular Node Dysfunction 208 Impaired Diastolic Function 208 Termination of CPB 209 Non‐Cardiac Surgery in the Post‐Cardiac Transplant Patient 210 Physiology of the Transplanted Heart 210 Autonomic Nervous System 210 Heart Rate 210 Left Ventricular Systolic Function 211 Right Ventricular Systolic Function 211 Atrial Function 211 Diastolic Function 211 Issues Unique to Heart Transplant Patients 211 Cardiac Allograft Vasculopathy (CAV) 212 Hypertension 212 Atrial and Ventricular Arrhythmias 212 Subacute Bacterial Endocarditis (SBE) Prophylaxis 213 Rejection 213 Response to Drugs 213 Anesthetic Considerations for Non‐Cardiac Surgery in Patients Post Heart Transplantation 215 30 Heart–Lung and Lung Transplantation 217 Introduction 217 Single‐Lung Transplantation 217 Double‐Lung Transplantation 217 Living Donor Lobar Lung Transplant (LDLLT) 218 The Donor 218 Operative Procedure and Patient Positioning 219 Use of CPB 220 HLT and En‐Bloc DLT 220 SLT and BSSLT 220 Anesthetic Management 221 Goals 221 Preoperative Evaluation 221 Premedication 221 Preinduction 221 Management of One Lung Ventilation (OLV) 222 Endobronchial Intubation 222 Single‐Lumen Endotracheal Tube Plus a Bronchial Blocker 222 Single‐Lumen Endotracheal Tube Plus an E‐Z Bronchial Blocker 222 Univent Tube 222 Double‐Lumen Endotracheal Tube 224 Induction and Maintenance 224 Special Considerations for SLT and BSSLT 225 One‐Lung Ventilation 225 Clamping of the PA 226 Allograft Implantation 226 Indications for CPB 226 Post‐CPB Management 227 Postoperative Care 227 Non‐Cardiac Surgery in Lung Transplant Patients 227 Anesthetic Considerations for Non‐Cardiac Surgery in Patients Post Lung Transplantation 229 31 Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA) 231 Introduction 231 Anatomy 231 Physiology 231 Surgical Treatment 231 Anesthetic Management 232 32 Heterotaxy 233 Introduction 233 Anatomy 233 Position of the Heart in the Chest 233 Atrial Anatomy 233 Venoatrial Connections 233 Ventricular Anatomy 234 Atrioventricular Junction 236 Ventriculoarterial Connections 236 Surgical Therapy 238 33 Ebstein Anomaly 239 Introduction 239 Anatomy 239 Physiology 239 Surgical Treatment 240 Anesthetic Management in Ebstein Anomaly 241 Goals 241 Post‐CPB Management 242 Index 243