Epidural Anesthesia for Cesarean Delivery and Vaginal Birth After Maternal Fontan Repair

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Abstract
The number of women reaching child-bearing age after undergoing a Fontan procedure to repair a congenital heart defect is increasing (14). This is most likely a consequence of the high long-term survival and the excellent quality of life resulting from this procedure (1–4). Origmally applied to patients with tricuspid atresia, the Fontan procedure, or one of its many modifications, has been used to treat a wide range of congenital lesions that share the common denominator of a single functional ventricle (3–6). The Fontan procedure is accomplished by surgically connecting the right atrium to the pulmonary artery either directly or via a valved conduit (Fig. 1) (1–6). There is no functional right ventricle; blood flow through the lungs is passive and depends on the pressure gradient between the systemic veins and the left atrium (5,6). This unique circulation may be unfavorably affected by anesthesia. Pulmonary vascular resistance (PVR) may be increased as a result of laryngoscopy and intubation during induction of general anesthesia. Venous return may be reduced as result of positive pressure ventilation. Without a right ventricle, these changes may significantly decrease blood flow to the lungs and could adversely affect oxygenation and cardiac output (5,6). Furthermore, the increased sensitivity of the single ventricle to the myocardial depressant effect of anesthetics and to arrhythmias may lead to hypotension after the induction of general anesthesia (5). In contrast to general anesthesia, epidural block provides surgical anesthesia probably without requiring endotracheal intubation or positive pressure ventilation and avoids the use of drugs that significantly depress the myocardium. Furthermore, the decreased vascular resistance accompanying the block may reduce the ventricular filling pressure and increase the gradient favoring flow across the pulmonary bed. Alternatively, epidural anesthesia may lead to a decrease in venous return, with detrimental effects on cardiac output. Finally, the epidural block can also be used to provide postoperative pain relief and effective analgesia for labor. We report two cases in which epidural block was successfully used to provide anesthesia for cesarean delivery and analgesia for vaginal birth in patients having previously undergone Fontan repair. This is the first case report dealing with the obstetric anesthetic management of post-Fontan patients.

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