11/21/2012

Anesthetic Management
in Fontan Circulation
Dr.Al Johara Hamza
Consultant Cardiac Anesthetist
Prince Sultan Cardiac Center

Anesthetic Management in Fontan Circulation

Understand cardiac anatomy and physiology
in Fontan patients.
Indication for Fontan operation.
Complications of Fontan circulation .
Anesthetic considerations.
Pregnancy and delivery.
Laparoscopic surgery.

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A Normal Biventricular Heart

Univentricular Heart

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Indications for Fontan Operation

Congenital heart disease when biventricular repair

is not possible.
Tricuspid atresia.
Pulmonary atresia with intact ventricular septum.
Double inlet left ventricle.
Hypoplastic left heart syndrome.

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Complications of a Fontan Circulation

Ventricular dysfunction.
Arrhythmias.
Thromboembolism.
Shunts.
Protein losing enteropathy.
Developmental deficit.

Anaesthetic Management
A full understanding of the physiology
of the Fontan circulation is essential
for ensuring optimal anesthetic
management of these patients.

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Anaesthetic Management
The main determinants of the success of the Fontan
circulation:

SVR.
PVR.
AV function.
Cardiac rhythm.
Ventricular function.

Disturbance of any of these factors compromise CO.

Anaesthetic Management
Preoperative Assessment.
Monitoring.
Induction and Maintenance.
Mechanical ventilation.

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Preoperative Assessment
History.
Examination.
Investigation.

Monitoring
Oxygenation.
Gas analysis.
Cardiac rhythm.
Invasive arterial and CVP monitoring is
MANDATORY

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Induction and Maintenance

Cardiac output may drop due to :
Myocardial depression.
Systemic vasodilatation.
Mechanical ventilation.

Induction and Maintenance

Avoid increase PVR.
Maintain:
SVR.
Myocardial contractility.
Cardiac rhythm.

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Mechanical Ventilation
Avoid increase airway pressure.
Low respiratory rate.
Short inspiratory time.
Low PEEP.
Low tidal volume (5-6 ml/kg).

Mechanical Ventilation
Disadvantages:

Mean intrathoracic pressure.

Venous return.
Pulmonary blood flow.
Cardiac output.

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Anesthetic Management

Pregnancy and Delivery

Pregnancy and Delivery

Physiological hemodynamical changes during
pregnancy have a significant influence on Fontan
patients:
Myocardial oxygen demand (20%).
Stroke volume (40%).
Heart rate (20%).
Fluid retention
tachyarrhythmia

atrial distention

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Anesthetic Management

Laparoscopic Surgery

Laparoscopic Surgery
Advantages:
Reduction in post operative pain and recovery
time.
Disadvantages:
Hypercarbia.
Gas embolism.
Hemodynamic disturbance.
Pneumothorax.
Mediastinal emphysema.

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Laparoscopic Surgery
Precautions:
Keep intra abdominal pressure less than
10 mmHg to maintain the venous return
and CO.
Maintain adequate ventilation
(avoid hypercarbia).
Minimize duration of surgery.
Maintain intravascular volume.

Conclusion
Understanding the physiology of Fontan
circulation is essential for the successful
anesthetic management.
Heart function in the pregnant patient with a
Fontan circulation deteriorates throughout
pregnancy.
Laparoscopic and day care surgery is usually
well tolerated.

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THANK YOU

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