Anesthetic management of pulmonary valve replacement for pulmonary regurgitation in six patients with surgically repaired tetralogy of Fallot

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease (CHD) encountered in CHD patients surviving into adulthood. A number of patients with surgically repaired TOF have significant pulmonary regurgitation (PR) that can lead to right ventricular (RV) dilatation, RV failure, and arrhythmia. We describe the anesthetic management for pulmonary valve replacement (PVR) in six PR patients with surgically repaired TOF. Although all patients had dilated RVs and depression of RV ejection fraction preoperatively, and arrhythmia and unexpected bleeding perioperatively, they could tolerate a well-managed PVR operation. Anesthesiologists should be aware of the multiplicity of comorbidities, sequelae, and residua in patients with surgically repaired TOF. RV function should be monitored using transesophageal echocardiography, and inotropic vasodilators and alpha-adrenergic agents should be administered, as appropriate. Arrhythmias, vascular injury during removal of adhesions during re-sternotomy, and bleeding from collateral vessels are also frequent complications.