Abstract 11656: Preoperative Cardiac Risk Assessment for a Patient With an Intracardiac Shunt Undergoing Laparoscopic Surgical Intervention

Abstract

Introduction: In this case, we discuss the intraoperative risk of air cardioembolic stroke in patients with intra-cardiac shunts undergoing laparoscopic surgery due to CO 2 insufflation of the abdomen in conjunction with provoked right-to-left shunting from anesthesia. Case Presentation: 27-year-old Female with Down Syndrome and asymptomatic VSD presented with abdominal pain. CT Abdomen performed revealed Acute Cholecystitis and patient was admitted for urgent laparoscopic cholecystectomy. Cardiology was consulted for preoperative risk assessment. Echocardiogram recommended and redemonstrated known VSD with predominant left-to-right shunting and occasional flow reversal (right-to-left) at baseline. Upon discussion with Anesthesia, the concern arose for anesthesia induced flow reversal of the shunt with a risk of possible paradoxical air embolism from CO 2 insufflation during laparoscopy. This concern was presented to the General Surgery team for consideration of conversion of procedure to open cholecystectomy. Open cholecystectomy was performed without complications. Discussion/Conclusion: Laparoscopic surgery requires CO 2 insufflation of the abdomen to cause pneumoperitoneum (Fig 1A), following which a gas embolism can result (Fig 1B). Consequently, in the absence of a pre-existing cardiac defect, patients can develop a pulmonary embolism (Fig 1C). However, individuals with right-to-left intracardiac shunting (Fig 1D), or Eisenmenger Syndrome, confer the additional risk of cardioembolic stroke (Fig 1E). In the preoperative assessment, right-to-left shunting is easily identified by TTE and managed accordingly. However, less intuitively, it can also occur transiently from the intraoperative use of certain anesthesia medications such as Propafol, which is known to decrease SVR. Therefore, if the evaluating clinician is unaware of this mitigated risk, it may go undetected, the result of which can be fatal.