Twenty Years of Anesthetic and Perioperative Management of Patients with Tetralogy of Fallot with Absent Pulmonary Valve

• Published in: Journal of cardiothoracic and vascular anesthesia 2017-06, Vol.31 (3), p.918-921
• Main Authors: Jochman, John D., MD, Atkinson, Douglas B., MD, Quinonez, Luis G., MD, Brown, Morgan L., MD PhD
• Format: Article
• Language: English
• Subjects: absent pulmonary valve; airway; Airway Management - methods; Airway Management - trends; Anesthesia & Perioperative Care; Child, Preschool; congenital heart disease; Critical Care; Female; Humans; Infant; Male; Perioperative Care - methods; Perioperative Care - trends; Pulmonary Valve - abnormalities; Pulmonary Valve - surgery; Respiration, Artificial - methods; Respiration, Artificial - trends; Retrospective Studies; tetralogy of Fallot; Tetralogy of Fallot - diagnosis; Tetralogy of Fallot - surgery; Time Factors
• ISSN: 1053-0770; 1532-8422
• DOI: 10.1053/j.jvca.2017.02.006

Objective Review our institutional experience of the induction and perioperative airway management of children with tetralogy of Fallot with absent pulmonary valve. Design Retrospective chart review. Setting Large academic children’s hospital. Participants Patients with the diagnosis of tetralogy of Fallot with absent pulmonary valve undergoing primary cardiac repair over a 20-year period was performed. Interventions None Measurements and Main Results Forty-four patients were identified with tetralogy of Fallot with absent pulmonary valve from January 1995 through August 2014. Forty-two patients (95%) required surgery in their first year of life. Sixteen patients (36%) required mechanical ventilation pre-operatively, including 11 neonates. Of the 28 patients not intubated pre-operatively, only one (3.8%) exhibited minor airway obstruction following induction that was managed uneventfully. All intubations in the operating room were performed in the supine position. Five patients who were mechanically ventilated preoperatively in a lateral or prone position were supinated in the operating room without significant cardiopulmonary compromise. There were no patients who suffered cardiopulmonary arrest or required mechanical circulatory support. The median time to extubation was 2 days (range 1-13 days) in those patients who were not mechanically ventilated prior to their operation. Ultimately, 5 patients required tracheostomy and 1 patient underwent lobectomy. Although, there was no mortality at 30 days, 4 children died within 1 year of their surgery. All the children who died had a genetic syndrome and required mechanical ventilation preoperatively. Conclusions While there are theoretical concerns specific to the induction and airway management of tetralogy of Fallot with absent pulmonary valve, there were no episodes of cardiorespiratory arrest or extracorporeal membrane oxygenation in our series. Neonatal age at time of surgery, preoperative need for mechanical ventilation, and concomitant genetic syndromes are risk factors for respiratory morbidity. Mortality in our study was low compared to historical reports, likely reflecting improvement in surgical technique and intensive care management.