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Anaesthetic Management of A Woman with Single Ventricle

Heart After BCPS who undergoes Curretage Procedure : A


Case Report
Adhi Gunawan Baskoro, Widya Istanto Nurcahyo
Department of Anesthesiology and Intensive Therapy of Medical Faculty Diponegoro
University / Dr. Kariadi General Hospital Medical Center

ABSTRACT
INTRODUCTION
Single Ventricle Heart is a rare and complex congenital heart disease. Congenital
heart disease occurs in 0.8% of newborns. Half of patients with congenital heart
disease who undergo heart surgery procedures are fertile age women. 1 The incidence
rate of Single Ventricle Heart disease is 3.2% of all incidents of congenital heart
disease.2 Patients with Single Ventricle Heart disease require special attention in
anaesthetic procedures due to a physiological change in the patient. We report
anaesthetic management in a woman after BCPS (Bidirectional Cavo-Pulmonary
Shunt) who undergoes curettage procedure. We will discuss the details of patient's
condition with Single Ventricle Heart and anaesthetic management in the patient.

CASE

A 28-year-old primigravida at 11 week of gestation with Single Heart Ventricle after


BCPS presented to the hospital by doctor's order to terminate her pregnancy on
indication of a heart condition that is intolerant with the pregnancy. The patient was
diagnosed with Single Ventricle Heart disease since childhood. The patient got her
heart disease checked to a doctor when she was 18 years old because she got tired
easily and had bruises on her body which increases over time. The patient consumed
Ramipril and Dorner routinely since then. Patient was then advised to perform cardiac
surgery. The patient underwent the first stage of BCPS surgery 1 year before the
termination of her pregnancy. Though she was required to undergo the next stage of
BCPS surgery, the patient never controls the condition of her heart after the surgery.
One month before admission, patient checked herself to the hospital and found herself
with 7 weeks single viable intrauterine pregnancy. It was recommended to terminate
her pregnancy due to her heart condition that intolerant with her pregnancy.
The patient's echocardiographic 1 week before termination shows Dextrocardia
Inversus Site with Mitral Atresia, Left Ventricle hypoplastic, Transpositional Great
Artery, Ventricular Septal Defect Inlet, Patent Foramen Ovale, Pulmonary Stenosis,
Bilateral bilateral BCPS, and Moderate Atriventricular Valve Regurgitation.
The patient was 11-weeks pregnant when admitted to the hospital for termination of
pregnancy. The patient is 163 cm height and 46 kg weight. The patient's blood
pressure was 110/70mmHg, the level of hemoglobin was 18.5 gr/dL and SpO2 78%.
The patient underwent 6-hours pre-operative fasting for the curettage preparation.
The curettage was performed with Spinal Anesthesia technique. Premedication of 2
mg of Midazolam and oxygenation using nasal cannule 3 liters per minute were given
before the induction. The patient was then given intrathecal injection of 5 mg of
Bupivacaine heavy 0.5% diluted with 1 ml of 0.9% NaCl using a 26 gauge spinal
needle on an intervertebral disc as high as L3-4 with 1.5 ml of local anesthetic
Lidocain 2%, then a prick test was performed to confirm the onset of intrathecal
anesthesia.
The curettage takes about 10 minutes. During curettage, the patient did not have
significant hemodynamic changes. During the surgery, the blood pressure was 103/78
and SpO2 83%. The patient had no complaint during the surgery. After the action was
completed, the hemodynamics was maintained stable and the patient was treated in
the recovery room then returns to the room after 1 hour of supervision in the recovery
room.

DISCUSSION
Bidirectional Cavo-Pulmonary Shunt (BCPS) or commonly referred as Bidirectional
Glenn Procedure or Partial Fontan is a procedure of transferring blood flow from
Vena Cava Superior which initially leads to the right atrium into the right pulmonary
artery. In BCPS, Vena Cava Superior is grafted with the right pulmonary artery so
that blood from the upper extremity goes directly to the pulmonary arteries without
passing through the heart chambers.
The purpose of the BCPS procedure is to reduce cardiac burden in patients with
Single Ventricle Heart disease and increase oxygen saturation compared to the BCPS
preoperative conditions. BCPS is also performed to prepare the heart for a Fontan
procedure by lowering pulmonary blood pressure.
In this patient, a termination was performed, due to in pregnancy the preload increase
by 20-30%. In this patient the new cavopulmoner shunting is done on the Superior
Vena Cava, while the Inferior Vena Cava still connects to the right atrium, thus
increasing the preload load in these patients will also increase the risk of pulmonary
hypertension. Patients with oxygen saturation rate at rest less than 85% also increases
the probability of fetal death.
The anesthetic chosen in the patient was to use low-dose anesthesia 5 mg of
bupivacaine heavy. The use of low-dose neuraxial anesthesia can provide adequate
analgesia without much effect on hemodynamic changes, where hemodynamic
stability is an important factor in patients with cyanotic heart disease. Provision of
low-dose neuraxial anesthesia has a short duration, but it is not a problem in this
patient because the operation was performed in 10 minutes.