Anaesthetic Management Of A Patient With

Atrial Septal Defect with Pulmonary

Hypertension Posted For Vaginal Hysterectomy
0 v 9 9
Dr.Manzar Hasan ; Dr.Milind Hatwalne ; Dr.Sharada Jali ; Dr.Tanuja Patil ;

Summary :
A 40 year old female patient posted for vaginal hysterectomy was diagnosed to have ostium secundum Atrial Septal
Defect (ASD) with mild tricuspid regurgitation with moderate pulmonary hypertension with mild essential
hypertension. We report the successful management of the case using combined general anaesthesia with epidural
analgesia.
Key words :
Atrial septal Defect, Pulmonary arterial hypertension, General Anaesthesia, Epidural analgesia.

Introduction : There was history of recurrent respiratory infection

Atrial septal defect is a common cardiac anomaly
that may be first encountered in the adult & occurs more
frequently in females.1 The sinus venosus type occurs
high in the atrial septum near the entry of Superior Vena
Cava(SVC) into the Right Atrium (RA) and is associated
frequently with anomalous pulmonary venous
connection from the right lung to SVC or RA. Ostium
primum anomalies lie adjacent to AV valves either of
which may be deformed or regurgitant. The most
common ostium secundum type ASD involves the fossa
ovalis & is midseptal in location. Patients with ASD are
usually asymptomatic in early life, although there may
be some physical underdevelopement & an increased
tendency for respiratory infections. Complications of
uncorrected secundum type of ASD include pulmonary
arterial hypertension, right sided heart failure, atrial
fibrillation or flutter, stroke & Eisenmenger's
syndrome.2 Changes in systemic vascular resistance
during the perioperative period have important
implications for patients with atrial septal defect.3
Literature on these patients is very limited. The
following case describes a patient with ostium
secundum type of ASD with moderate pulmonary
hypertension with mild TR with mild essential
hypertension who successfully underwent vaginal
hysterectomy under combined approach of general
anaesthesia with epidural analgesia.
Case Report:
A 40 year old female weighing 50 kgs was admitted
with history of vaginal bleeding for the past 6 months.
Patient was a mother of three children, all, apparently
being uncomplicated hospital deliveries.
Authors & Correspondence
0 Professor,
v Associate ProfessorV
9 Tutors,
Department of Anaesthesiology, Khaja
Banda Nawaz Institute Of Medical Sciences,
Gulbarga-585102,
V Dr.M.S.Hatwalne,
Email:drmshatwalne@rediffmail.com
11
and mild limitation of physical activity ; after
admission, she was referred to cardiologist, when she
was diagnosed to have ASD ostium secundum type. She
was also a known case of essential hypertension
diagnosed two years back and on oral nifedepine (slow
release 20mg, twice a day) and Torsemide with
Spironolactone.No additional drugs were advised for
the ASD by the cardiologist.
On examination her pulse rate was 88/min (Regular)
and arterial blood pressure was 130/90 mm of Hg.
Jugular Venous Pulse was normal. Cardiovascular
system examination revealed a loud P2 , Ejection
Systolic Murmer gr. IV/VI in pulmonary area.
Respiratory system evaluation was normal. All
biochemical, haematological & coagulation tests were
normal.Chest X-Ray revealed prominent of central
pulmonary vessels & cardiomegaly. EKG revealed-
Right Bundle Branch Block & Right Axis Deviation.
Echocardiogram showed – OS type ASD (18mm) with
Left to Right (L to R) shunt, RA & RV dilated , Mild
Tricuspid Regurgitation, Systolic pulmonary artery
pressure of 51mm Hg and Ejection Fraction of 65% .
Ultrasound revealed bulky uterus with thickened
endometrium. Patient was diagnosed to have
Dysfunctional Uterine bleeding with OS type ASD with
L to R shunt with moderate pulmonary arterial
hypertension with mild essential hypertension & was
posted for vaginal hysterectomy.
Morning dose of oral Nifedipine was given 2 hours
prior to shifting to OT with sip of water. Inj.Ceftriaxone
2gm & Inj.Gentamicin 80 mg IV were given
preoperatively as matter of institutional protocol.
Patient was preloaded with 500 ml of Ringr Lactate.
Basal BP was 126/84 mm Hg and Pulse 88/min. Patient
was premedicated with Inj. Glycopyrrolate 0.2mg, Inj.
Diazepam 5mg, Inj. Ondansetron 4mg, Inj. Ranitidine
50mg, Inj.Butorphanol 1mg IV. An 18G epidural
catheter was placed in L2-3 interspace with loss of
resistance to saline technique. Right side internal
jugular vein was cannulated using 16G catheter under
local anaesthesia by Seldinger technique & Inj. Nitrogly
-cerine was started at the rate of 0.5 mcg / kg / min.
Patient was preoxygenated with 100% oxygen for 3
mins, using Magill's circuit. Induction was performed
with Inj.Thiopentone Sodium 250 mg IV.The patient
was intubated with 7.5 No.cuffed ETT under the effect
of Inj.Succinylcholine 75mg IV. BP and HR after
induction and during intubation were 108 / 80 mm Hg
and 98/min and 140/94 mm Hg and 104/min.
respectively. Patient was maintained on IPPV using
Bain's circuit with 100% oxygen & 0.5% halothane
intermittently under the effect of Inj.Vecuronium.
Epidural analgesia was supplemented with
Inj.Bupivacaine 0.125% (volume of 10 ml) through
epidural catheter. Patient was positioned in modified
lithotomy (Hip to trunk at 1100) to avoid excess
compression on veins) and table was kept flat.
Intraoperative monitoring included 3 lead ECG,
pulse oximetry, temperature, capnography,hourly
urine output & noninvasive BP & CVP. All the
parameters were stable. Surgery lasted for 90
min.Intraoperatively patient received 500 ml RL and
500ml DNS; the patient was reversed with
Inj.Neostigmine 2.5mg + Inj.Glycopyrrolate 0.5mg IV.
Postextubation patient was conscious, responding to
verbal commands with normal muscle power &
relatively stable BP,HR and SpO2. The patient was
maintained on face mask oxygen at 41/min in post
operative ward. Nitroglycerine was continued in post
operative period and titrated in the background of
epidural analgesia; BP and HR remained within a
narrow acceptable range, (compared to the basal
values) and nitroglycerine was tapered off after 8
hours.Analgesia was maintained with epidural top up
of 0.125% bupivacaine & 75mcg buprenorphine.
Epidural analgesia was continued for two days,
followed by oral analgesics.Patient was allowed oral
diet on 2nd day, after return of bowel and bladder
function. Her condition in the hospital till discharge on
7th day was uneventful.Patients cardiac medications
were resumed on the second post operative day.
2D echocardiography was done which showed a
systolic pulmonary artery pressure of 50 mmHg.She
was discharged after 7 days & was referred back to
cardiologist for medical follow up.
Discussion
WHO classification of systemic to pulmonary shunts –
Venice 2003.4
1) Type- Simple : ASD, VSD, PDA, anomalous venous
return.
- Combined: describe combination & define
prevalent defect if any.
- Complex: Truncus arteriosus, Single ventricle,
AV septal defects.
2) Dimensions: Small ( ASD < 2cm, VSD < 1cm) or large
>2cm.
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3) Associated cardiac abnormalities
4) Correction status: non, partially or totally corrected.
WHO classification of pulmonary arterial
hypertension functional status.5
I - No limitation of usual physical activity : Ordinary
physical activity does not cause increased dyspnoea,
fatigue, chest pain or presyncope.
II - Mild limitation of physical activity. There is no
discomfort at rest, but normal physical activity causes
increased dyspnoea, fatigue, chest pain or presyncope.
III - Marked limitation of physical activity. There is no
discomfort at rest, but less than ordinary activity causes
increased dyspnoea, fatigue, chest pain or presyncope.
IV - Unable to perform any physical activity at rest and
may have signs of RVF.Dyspnoea &/ or fatigue may be
present at rest and symptoms are increased by almost
any physical activity.
Pulmonary hypertension is classified as mild (36-49
mm of Hg systolic),moderate (50-59 mm of Hg),severe
(>60 mm of Hg) according with right ventricular
systolic pressure calculated by Echocardiography.2 70%
ASDs are of OS type. Female to Male ratio is 2:1.There is
a tendency for familial involvement : significant ASD is
associated with P.R prolongation or forearm & hand
abnormalities (Holt-Oram Syndrome).
Perioperative mortality rate is 1%. Life expectancy
without repair is 40yrs.6 Risks of death increase with
age.7 The two major complications of ASD are
pulmonary arterial hypertension & right ventricular
failure. In about 15% of cases, elevated PVR developes
after adolescence. As a result of chronic volume
overload, patients older than 40 years may develop RVF
leading to atrial dysrhythmias, TR & eventually CCF.7
Our patient was in the vulnerable age group & had mild
TR.
Anticipated problems are :- 6 Air embolism during
vascular access, Dysrhythmias (5- 10% if no prerepair
dysrhythmia.), Heart failure, Heart block and in some
situations, Infective Endocarditis. The current
recommendations does not warrant pre operative
antibiotics in our case for prophylaxis against infactive
Endocarditis. Preloading with RL was done to avoid
any drastic fall in blood pressure with IV induction as
the patient was on Nifedepine and because we decided
to give bupivacaine by epidural catheter. We preferred
combined approach of general anaesthesia with
controlled ventilation with epidural analgesia because
it provides better haemodynamic stability. 100%
oxygen could be given as the patient had moderate
pulmonary hypertension. Halothane, Diazepam and
Butorphanol with benefits of amnesia and analgo-
sedation permitted the use of 100 % oxygen. Isoflurane
could be a practically useful agent and so would be
sevoflurane. Since we did not have both agents,we went
ahead with use of halothane. Butorphanol, a mixed
agonist antagonist opioid is relatively cardio stable.
However, we have to guard against respiratory
depression by proper monitoring.Hypercarbia can be
avoided by mechanical ventilation. In addition,by
stretching the lungs, positive pressure ventilation leads
to release of prostaglandins which cause pulmonary
vasodilatation.8 Regional anaesthesia with desired
level of analgesia will cause marked reduction in
SVR.Positive pressure ventilation of lungs is well
tolerated in increased pulmonary blood flow.3 PAH
may be treated with vasodilators & oxygen.
Nitroglycerin used in low doses is desirable in patients
with pulmonary hypertension as it helps to decrease
pulmonary vascular resistance & improves
transpulmonary filling of LV.Low dose NTG infusion is
very useful; inhaled NO is expensive,needs specialized
delivery system and it is associated with increased
bleeding time and negative inotropic effect.9 Systemic
effects of NTG is beneficial in our patient as patient had
mild essential hypertention.Incidence of hypertension
due to laryngoscopy & intubation is less in patients
receiving continuous infusion of NTG. Morning dose of
nifedipine was given, as Ca2+ antagonists reduce PVR
& PAP. 10 We used epidural catheter insertion with loss
of resistance to saline technique to avoid air embolism.
Epidural analgesia was preferred for the benefit of
excellent analgesia, to avoid tachycardia and
sympathetic stimulation. Theoretically IV induction
may be slowed by presence of L to R shunt. Nitrous
oxide may increase PVR & may increase the size of air
bubble. Ketamine can increase PVR. So we avoided the
use of nitrous oxide & ketamine. Vecuronium and
butorphanol are relatively cardiostable. Monitoring of
PAP & PCWP was not possible at our institute so we
resorted to 2D echocardiographic evaluation of
pulmonary arterial pressure. Intraoperative
hypothermia, hypercarbia & hypoxaemia were
avoided as these factors are known to cause shunt
13
reversal.Steep head end down and excessive lithotomy
position was avoided to prevent dangerous alterations
in hemodynamics. The magnitude of left to right shunt
depends on ASD size, ventricular diastolic properties &
the relative impedance in the pulmonary & systemic
circulation. 1 Therefore the goals of anaesthetic
management were to avoid further increase in PVR,to
avoid marked reduction in SVR and to avoid
myocardial depression.
Conclusion :
It can be concluded from the case report that patients
with ASD with pulmonary hypertension can undergo
non cardiac surgery if adequate precautions are taken
keeping in mind the pathophysiological changes.
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7. Wylie and Churchill-Davidson s A Practice Of Anaesthesia, 7th
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