Tetralogy of Fallot

Abstract

Congenital heart disease has only recently evolved within the expertise of the pediatric or cardiac anesthesiologist as pediatric cardiac anesthesiology has become recognized as a discrete subspecialty (DiNardo et al., Anesth Analg 110(4):1121–1125, 2010). Historical attempts to “simplify” the cardiac malformations that may be encountered typically ignored specific anatomic details in favor of slotting the lesions into broad categories such as “cyanotic” or “noncyanotic,” often understating the fluidity of said lesion under different clinical circumstances. Early textbooks on anesthesia for the congenital cardiac patient often divided cardiac anomalies in very general ways, pointing out specific memorable features associated with some lesions (Lake, Pediatric cardiac anesthesia, McGraw-Hill/Appleton and Lange, New York, NY, 1993). Although useful in the era where most anesthesiologists did not have significant insight into this subspecialty of pediatric disease, rapid advances in the successful surgical treatment of congenital cardiac disease have been paralleled by accumulation of specific cognitive and technical skills by anesthesiologists dedicated to the care of such patients (DiNardo et al., Anesth Analg 110(4):1121–1125, 2010). Present-day pediatric cardiac anesthesiologists share knowledge of congenital cardiac disease, echocardiography, and the physiologic challenges of catheterization lab procedures with the pediatric cardiologist; the details of surgical technique and management of cardiopulmonary bypass (CPB) with the cardiac surgeon; and the management and expectations of preoperative care and postoperative convalescence (including the management of extracorporeal membrane oxygenation) with the pediatric cardiac intensive care physician. The assessment of a patient with congenital heart disease by the contemporary pediatric cardiac anesthesiologist is a complex synthesis of the anatomic details of a specific cardiac lesion, the patient’s status within the natural history of the lesion, consideration of how anesthesia techniques and the operative environment will predictably intrude on the homeostasis of the patient’s cardiac physiology, and how those risks might be tolerated and minimized. The author’s goal for the next two chapters is not to present an encyclopedic review of the material with inarguable advice on anesthesia technique and management. Instead, a contextual presentation including embryology and anatomy, physiology correlated with the anatomy, medical and surgical management, and the natural history of the disease is presented with the assumption that a well-informed practitioner can apply their enhanced knowledge of the cardiac disease in making informed choices regarding anesthesia management.