Minutes of the Meeting
30th November 2016
‘Anaesthesia & the Adult with Congenital Heart Disease’
Dr S Balaji, Consultant Cardiac Anaesthetist, Leeds Teaching Hospital NHS Trust
President, Dr Clare Howard opened the meeting and welcomed Dr Balaji to the LSA.
Dr Balaji started his presentation by addressing concerns about adults with congenital heart disease (CHD). He said the incidence remains stable at 1:145 babies, but the survival rate is increasing meaning that we are seeing more patients with complex CHD presenting for non-cardiac surgery and this number is expected to increase. He went through the incidence of the various types of CHD with atrial or ventricular septal defects (ASD/VSD) being the commonest form (22%) and Eisenmenger’s syndrome being the rarest (3%). He described adults with CHD having residual problems or sequale of CHD, which can be mechanical, functional or electrophysiological issues.
Dr Balaji then went on to describe the specific disorders of ASD, VSD, Coarctation of the Aorta (CoA), Tetralogy of Fallot (TOF), Transposition of the great arteries (TGA), Ebstein’s anomaly, Left ventricular outflow obstruction and Eisenmenger’s syndrome. He showed the audience videos of transoephageal echos (TOE) and 3D TOEs of patients with ASDs. He discussed the various treatment options for ASD including surgery and device closure and showed a 3D TOE demonstrating the Amplatzer septal occluder. He then discussed the 4 different types of VSD. He spoke about Tetralogy of Fallot, the anatomy and showed some echos of patients with TOF. He spoke about the approaches for repair and the consequences of surgery including right ventricular (RV) dysfunction, pulmonary hypertension and pulmonary valve leak. He went through the anaesthetic considerations and abnormalities due to RV dysfunction (due to pulmonary regurgitation), exercise intolerance, ventricular arrhythmias and sudden death.
Dr Balaji described the direction of blood flow in TGA and the various repair options including the atrial switch procedures and their anaesthetic implications. He talked about Ebstein’s Anomaly, the distortion and displacement of tricuspid valve leaflets and he used an echo to demonstrate it. He said pregnancy is usually well tolerated by these patients but they are prone to arrthymias especially Wolff-Parkinson-White syndrome. He discussed the poor prognostic signs including: male sex, cardiothoracic ration of >0.65 on CXR and septal leaflet attachment ratio. He then covered Coarctation of Aorta and the anaesthetic considerations of on-going hypertension, recurrent CoA, aneurysm and endovascular infection. Dr Balaji discussed Eisenmenger’s syndrome and the anaesthetic implications and the balance needed as a decrease in systemic vascular resistance (SVR) worsens cyanosis but an increase in SVR worsens ventricular function, arrhythmias cause decompensation and patients are at risk of systemic embolism.
He discussed cardiovascular impairment in CHD and the factors causing it: hypoxaemia, pulmonary abnormality, cardiac failure and arrhythmias. He elaborated on the effects of chronic hypoxaemia on the cardiovascular system causing myocardial dysfunction, polycythaemia, hyperviscosity syndrome and abnormal haemostasis.
He concluded his talk by focussing on congenital cardiac lesions and pregnancy. He said 66% of all heart disease in pregnancy is due to CHD. The prevalence is remaining stable but the complications are increasing. CHD deaths are actually decreasing but deaths due to other forms of heart disease are increasing.
He discussed the modified WHO maternal risk categories and lesion specific outcomes in pregnancy. Dr Balaji went through the normal haemodynamic changes in pregnancy then discussed the haemodynamic adaptations in CHD and maternal risk predictors. He concluded by speaking about specific problems in pregnancy related to TGA, pulmonary hypertension and univentricular hearts. He took some questions from the floor and the vote of thanks was given by Dr Phil Arnold.
Dr Gemma Roberts