Heart Rate – Cardiac output is very dependent on an elevated heart rate. The rate should be normal to slightly high. Too high of a rate may compromise ventricular filling.

Preload – Augment preload.

Avoid worsening the condition – Airway obstruction, hypoventilation, hypoxia, and pulmonary hypertension create greater pressures on the right side of the heart. If a right-to-left shunt is present, these may reverse the shunt (making it a cyanotic shunt). This is otherwise called Eisenmenger Syndrome.

This is a congenital heart defect. It is not unusual for other congenital heart defects to be present (specifically Atrial septal defect (ASD) and patent foramen ovale (PFO). Broad anesthetic implications of acyanotic congenital heart defects (CHD) include the rest of the points below:

Get a detailed medical history – understand all you can about what defect the patient has and how severe the symptoms are. Get surgical history, daily medications, hemodynamic status, and cardiac and lung function.

Reduce left-to-right shunt – Increases in SVR will worsen left-to-right shunting. Sudden increases or decreases in pulmonary vascular resistance or SVR will also be tolerated poorly. Volatile anesthetics, propofol, etomidate, and barbiturates all decrease SVR – so use cautiously.

Limit stress – or anything that would stimulate sympathetic response. Opioids are often used to reduce/eliminate sympathetic responses to pain, laryngoscopy, etc. Use a slow/cautious induction.

Maintain MAP and SVR – Arterial lines and/or central lines are ideally employed to keep tight controls. These patients will not have optimal cardiac reserve.

Debubble – avoid any bubbles in venous lines. If a right-to-left shunt is present, these can lead to a paradoxical embolus.

Cardiac bypass – complex congenital defects sometimes require this. Be aware that this may result in hemodilution!

Endocarditis prophylaxis – for 6 months post-surgical repair of the cardiac defect.

This acyanotic congenital heart defect (CHD) accounts for 8-10% of all congenital heart defects.

Pulmonic stenosis is characterized by an obstruction of blood flow from the right ventricle to the pulmonary artery. This causes backup of flows and concentric hypertrophy of the right ventricle. This is often due to a malformed pulmonic valve. The valve may be bicuspid or tricuspid and the leaflets may be partially fused. ASD and PFO may also be present.

Severe and symptomatic versions of this typically present in the neonatal period. Less severe forms (asymptomatic) can go undetected until adulthood.

Signs and symptoms – a harsh systolic murmur and thrill may be heart. Right ventricular hypertrophy, prominent P waves on the EKG, and R axis deviation may also be present. The array of symptoms are typical of those with right heart failure: activity intolerance, dyspnea, peripheral cyanosis,

Treatment – balloon dilation