Anesthesia Considerations 

Atrial Septal Defect (ASD) 

 

 

Considerations

 

• Etiology & severity of ASD: Size, shunt (L→R / R→L)

• Complications of chronic L to R shunt:

  • Arrhythmias (atrial fibrillation & supraventricular tachycardias)

  • Pulmonary HTN, RV dysfunction, shunt reversal (R→L with hypoxemia)

  • Tricuspid valve & pulmonic valve disease  

• ↑ perioperative risk of:

  • Arrhythmia, pulmonary hypertension crisis, RV dysfunction/failure

  • R→L shunt reversal: hypoxemia, paradoxical air embolism 

  • Paradoxical embolism (air, CO2, septic, thrombus)

• Comorbid disease:

  • Adult congenital heart disease, Down syndrome, etc

  • Previous closures

• Medications: anticoagulation, antiarrhythmics

• Considerations for closure of ASD:

  • Out of OR considerations

  • Complications (tamponade, arrhythmias, valve disruption, & emboli)

 

 

Goals

 

• Hemodynamic goals:

  • Preload: maintain adequate preload 

  • Rate: maintain normal rate 

  • Rhythm: maintain normal sinus rhythm 

  • Contractility: maintain adequate contractility 

  • Afterload: avoid extremes of systemic vascular resistance;  ↑ SVR may precipitate pulmonary hypertension & RV dysfunction, ↓ SVR may cause R→L shunting & hypoxemia

• De-air lines (risk of pulmonary air embolism) 

 

 

Pregnancy Considerations 

 

• Pregnancy is well-tolerated if pulmonary hypertension not present 

• Control of SVR critical to limiting bidirectional shunting

• Labour: early titrated epidural preferred

• For epidural, do NOT use loss of resistance to air (use saline)

• C-section: give anesthetic by titrated epidural