الفهرس 
Pathophysiology of Adult Congenital Heart DiseasesOnly 14 pages are availabe for public view
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Abstract
Adult congenital heart diseases (ACHD) have become
more prevalent in the surgical population and so can be
encountered in the daily practice. Adult patients with
congenital heart disease present the anesthetist with unique and
varied challenges. Individualized care of these fragile patients
should be approached with a keen understanding of the
patient’s underlying cardiac anomaly.
Due to the variable nature of ACHD with R-to-L shunts,
perioperative anesthetic care should be considered as a multidisciplinary
strategy in order to improve the management and
outcome of patients undergoing surgery and to come up with a
safe interdisciplinary peri-procedure plan with better surgical
and medical outcome.
Anesthesiologists as perioperative physicians play a key
role in non-cardiac surgery of R-to-L shunt patients, through
their choice of preoperative medication, anesthetics and
techniques as well as the administration of adjunctive drugs to
maintain major organ system function during and after
surgery.
In preoperative assessment, the ACHD patient’s history
may be incomplete or misleading due to misapprehension of
”cure” while in fact active issues still remain and impact
importantly the management plans. Patients with congenital
heart disease (CHD) are also susceptible to the acquired
cardiovascular and non-cardiovascular diseases that accrue
with age.
The patient’s cardiac functional status is assessed from
history and preoperative investigations - including routine labs
plus a good review of cardiac anatomy via echocardiography
(with shunt and clot check) and cardiac catheterization -which
are recommended as they might modify the contemplated
Summary
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procedure, the anesthetic technique or the nature of
monitoring.
The main preoperative role is to optimize the patient for
the planned intervention as much as possible and to manage
perioperative anticoagulation and cardiac medications, in
addition to the preoperative choice of suitable monitoring and
adequate technique and mode of ventilation. These are all
critically essential to positively influence the postoperative
outcome in ACHD patients.
In ACHD patient with R-to-L shunt, an intraoperative
focus on the preservation of oxygenation and minimization of
intracardiac shunting is considered to be the mainstay,
achieved by providing adequate preload and maintaining
balance between pulmonary and systemic blood flows and thus
adequate oxygen delivery.
Cautious administration of sedatives and anesthetic agents
in these CHD patients and the experience with factors
affecting monitoring and interpretation of the resultant
readings is mandatory.
Postoperative issues such as need for postoperative
ventilation, or invasive monitoring, stay at the ICU and pain
management should be addressed in a calm environment
before the planned procedure rather than discussing it at the
conclusion of the intervention. Most patients are better
managed in a close observation unit where tight hemodynamic
monitoring exists.
Adult CHD patients with right-to-left shunt are at
increased risk with non-cardiac surgery, but with current
modern techniques, the risk of morbidity and mortality is less
than previously thought. With careful planning by the surgical
and anesthesia care team, adult patients with congenital heart
disease in the vast majority of cases may be successfully
anesthetized for non-cardiac surgery without incident