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LETTER TO THE EDITOR
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 102-103  

Anesthetic management for laparoscopic surgery in a patient with Ebstein's anomaly


Department of Anaesthesia, M.S. Ramaiah Medical College, Benagaluru, Karnataka, India

Date of Web Publication9-Jan-2017

Correspondence Address:
Dr. Leena Harshad Parate
Department of Anaesthesia, M.S. Ramaiah Medical College, Benagaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.197918

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How to cite this article:
Parate LH, Tejesh C A, Geetha C R. Anesthetic management for laparoscopic surgery in a patient with Ebstein's anomaly. Med J DY Patil Univ 2017;10:102-3

How to cite this URL:
Parate LH, Tejesh C A, Geetha C R. Anesthetic management for laparoscopic surgery in a patient with Ebstein's anomaly. Med J DY Patil Univ [serial online] 2017 [cited 2022 Sep 25];10:102-3. Available from: https://www.mjdrdypu.org/text.asp?2017/10/1/102/197918

Sir,

Ebstein's anomaly (EA) is a rare congenital heart disease, affecting 1/200,000 live births and accounts for <1% of congenital heart diseases.[1] The anomaly consists of downward displacement of the septal and posterior leaflet of tricuspid valve resulting in atrialization of the right ventricle and tricuspid regurgitation. Displacement of septal leaflet creates substrate for accessory conduction pathways resulting in tachyarrythmias.

A 25-year-old female, a known case of EA was posted for laparoscopic cholecystectomy. She was hemodynamically stable with no signs of heart failure pansystolic murmur was audible in the tricuspid area. Electrocardiogram (ECG) revealed first-degree heart block. Echocardiogram revealed posterior leaflet displacement by 49 mm and septal leaflet displacement by 18 mm [Figure 1]. There was severe tricuspid regurgitation with small right ventricular (RV) functional cavity and left ventricular ejection fraction was 65%. The right atrium was moderately enlarged with size 4.9 cm. There was no interatrial communication.
Figure 1: Two-dimensional echogram showing displacement of septal tricuspid leaflet and small volume right ventricle

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She was premedicated with alprazolam 0.25 mg p.o. and intravenous (IV) pantoprazole 40 mg on the night before surgery. Anesthesia monitoring was done with ECG, invasive blood pressure and pulse oximetry. She was sedated with 1 mg midazolam and 100 µg IV fentanyl. Anesthesia was induced with inhalational agent sevoflurane 4% and intubation was facilitated with atracurium. Anesthesia was maintained with oxygen, air and isoflurane on pressure controlled ventilation. Following anesthesia induction, she had one episode of hypotension which was treated with IV 50 µg phenylephrine. Ventilation was adjusted so as to avoid hypercapnia. Carbon dioxide (CO2) was insufflated at the rate of 2 L/min and intrabdominal pressure (IAP) was kept at 10 mmHg. She remained hemodynamically stable throughout the procedure. Total 1.2 L of crystalloid was given. Her postoperative course was uneventful.

Pooling of drugs in an enlarged right atrium can result in slow IV induction and delayed response to inotropes.[2] The risk of paradoxical air embolism is high as interatrial communications are invariably present in EA. Insertion of central venous catheter carries the risk of serious arrhythmias and bacterial endocarditis.

Hypoxia and hypotension worsen the right to left shunting. Treatment of hypotension with conventional fluid and vasopressors may result in further instability in these patients.[3] Ephedrine a potent beta-agonist can precipitate supraventricular tachycardia. Phenylephrine is preferable as it is a selective alpha agonist. There is 20% incidence of supraventricular tachycardia during general anesthesia induction. Tachycardia is poorly tolerated as it impairs the filling of functionally small volume RV. Esmolol is a short-acting agent and achieves rapid control of heart rate.

Pneumoperitonium results in reduction in preload and increase in afterload. The combined effect of anesthesia, head up tilt and pneumoperitonium produces 50% reduction in cardiac index. Exogenous CO2 can provoke dysrhythmias. These hemodynamic fluctuations can be minimized by keeping IAP around 8–10 mmHg and slow insufflation of CO2.[4] Kumar et al. reported a case of prone position induced a reduction in cardiac output and sudden cardiac arrest in a child with EA who had well-preserved cardiac function.[5]

We preferred inhalational induction over IV as inhalational route provide more stable hemodynamics and faster recovery.[6] Hence, we conclude irrespective of the severity of the lesion, meticulous monitoring is essential in such patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Attenhofer Jost CH, Connolly HM, Dearani JA, Edwards WD, Danielson GK. Ebstein's anomaly. Circulation 2007;115:277-85.  Back to cited text no. 1
    
2.
Elsten JL, Kim YD, Hanowell ST, Macnamara TE. Prolonged induction with exaggerated chamber enlargement in Ebstein's anomaly. Anesth Analg 1981;60:909-10.  Back to cited text no. 2
    
3.
Choudhuri AH, Uppal R, Khaitan M. Laparoscopic cholecystectomy in a patient with Ebstein's anomaly: Anesthetic considerations. Saudi J Anaesth 2012;6:301-2.  Back to cited text no. 3
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4.
Umar A, Mehta KS, Mehta N. Evaluation of hemodynamic changes using different intra-abdominal pressures for laparoscopic cholecystectomy. Indian J Surg 2013;75:284-9.  Back to cited text no. 4
    
5.
Kumar MS, Gangaprasad, Vadhanan P. Prone position induced cardiac arrest in an Ebstein's anomaly child. Paediatr Anaesth 2009;19:65-6.  Back to cited text no. 5
    
6.
Liao R, Li JY, Liu GY. Comparison of sevoflurane volatile induction/maintenance anaesthesia and propofol-remifentanil total intravenous anaesthesia for rigid bronchoscopy under spontaneous breathing for tracheal/bronchial foreign body removal in children. Eur J Anaesthesiol 2010;27:930-4.  Back to cited text no. 6
    


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