• Jose C A Carvalho, Mathew Sermer, Jefferson Clivatti, Rebecca L Smith, and Candice Silversides.
• Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON, Canada.
• Can J Anaesth. 2012 Dec 1;59(12):1119-24.

PurposeTetralogy of Fallot (TOF) is one of the most common causes of cyanotic congenital heart disease. The anesthetic management of parturients with uncorrected TOF is challenging and controversial, especially for Cesarean delivery (CD). We describe the use of noninvasive cardiac output (CO) monitoring to assist the management of CD for a woman with palliated TOF under general anesthesia.Clinical FeaturesA 34-yr-old woman presented for elective CD at 38 weeks gestation. Having been born with TOF, she underwent a modified Blalock-Taussig shunt at six years of age, followed nine years later by creation of an aortopulmonary connection. The patient's functional status was New York Heart Association class I despite evident central cyanosis. A CD was performed under general anesthesia. Fentanyl, etomidate, and succinylcholine were utilized for induction, and intrathecal morphine was administered for postoperative pain control. The baseline CO (7.2 L·min(-1)), blood pressure (156/74 mmHg), heart rate (74 beats·min(-1)), and total peripheral resistance (1,059 dynes·sec(-1)·cm(-5)) remained stable throughout the procedure. Maintenance anesthesia consisted of rocuronium, sevoflurane, and an oxygen/nitrous oxide mixture. Upon delivery, an infusion of oxytocin combined with ergometrine was administered. Hemodynamic parameters remained stable and no vasopressor was required.ConclusionBalanced general anesthesia and careful titration of uterotonic agents provided stable hemodynamic conditions during CD in a patient with a palliated TOF, as assessed by a continuous noninvasive CO monitor. Noninvasive CO monitoring may improve our understanding of the hemodynamic implications of various anesthetic techniques for CD in cardiac patients.

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