We present a case report on anaesthetic management of a case of hemianomalous pulmonary venous connection with VSD, ASD for total intracardiac repair. A balanced anaesthetic technique was used with oxygen, isoflurane, fentanyl, midazolam, vecuronium. Patient was successfully operated under cardiopulmonary bypass with hypothermia.

1. Anaesthetic Management of A Rare Case of Hemianomalous
Pulmonary Venous Connection

2. Case Report
A 11 month old malnourished baby boy, weighing 5kg
came with complaints of failure to thrive and recurrent
URI. His general physical examination was normal and
cardiovascular examination revealed a systolic murmur
and heart sounds were of equal intensity on both sides of
the chest. His routine investigations were normal with
hemoglobin of 14 g%. His chest X-ray showed
dextrocardia, cardiomegaly and pulmonary plethora. His
ECG showed upright r-waves in V1. 2D Echo showed situs
solitus, mesocardia, bilateral superior venacava, dilated
coronary sinus, cardiac TAPVC, perimembranous VSD,
ostium secundum ASD (R→L), severe PAH, dilated
pulmonary artery, severe TR.
Patient was posted for total intracardiac repair under
general anaesthesia and cardiopulmonary bypass.The baby
was given intramuscular ketamine 25 mg and atropine
0.05mg and shifted to OT. Routine monitors were
connected. His saturation on room air was 86%. In the OT
general endotracheal anaesthesia was given with no 4
(UNCUFFED) tube after inducing with inj. fentanyl
20mcg, inj. Midazolam 1mg and inj.vecuronium 1mg iv.
During preoxygenation the saturation increased to 94%
and with intubation attained 100%. Left femoral arterial
line was secured with 20G iv cannula and left radial
arterial line was secured with 24 G iv cannula. Right
internal jugular vein was secured with 5 french, 8 cm
catheter. Maintenance was with 100% oxygen, isoflurane
0.8-1% and vecuronium.
After heparinisation (2500U) and obtaining a
satisfactory ACT patient went on CPB. Peroperative
findings were as follows-absent innominate vein, bilateral
ANAESTHETIC MANAGEMENT OFARARE CASE OF
HEMIANOMALOUS PULMONARY VENOUS CONNECTION
KR Manjunath*, S Shwetha Odeyar**, Murali Krishna***, Shyam P Shetty***
and Keshav Murthy****
*Consultant Cardiac Anaesthetist, **PG Student in Anaesthesia, ***Consultants in Cardio thoracic Surgery,
****Consultant Cardiologist, Apollo BGS Hospitals, Mysore 570 023, India.
Cooespondance to: Dr KR Manjunath, Consultant CardiacAnaesthetist, Apollo BGS Hospitals, Mysore 570 023, India.
We present a case report on anaesthetic management of a case of hemianomalous pulmonary venous
connection with VSD, ASD for total intracardiac repair. A balanced anaesthetic technique was used with
oxygen, isoflurane, fentanyl, midazolam,vecuronium.Patient was successfully operated under
cardiopulmonary bypass with hypothermia.
Key words: Hemianomalous pulmonary venous connection(HAPVC), Atrial septal defect(ASD).
SVC, left atrial isomerism, situs solitus with
dextroversion, ostium secundum ASD, dilated coronary
sinus, left pulmonary veins draining into left atrium, right
pulmonary veins draining into right atrium near the
coronary sinus, perimembranous VSD, large pulmonary
artery and normal relation of great arteries. Had the right
pulmonary veins drained into coronary sinus directly, it
would have been a real challenge to re-route the
pulmonary veins into left atrium as left superior vena cava
was draining into coronary sinus. As there was left atrial
isomerism we expected that sinoatrial node was located in
an unusual location with high possibility of developing
heart blocks. On full CPB, aorta cross clamped and cold
blood cardioplegia given. Patient was cooled to 28ºC,
pediatric membrane oxygenator used (minimax plus),
nonpulsatile flow achieved and hemofiltration done and
550 mL of water removed. ASD enlarged and right
pulmonary veins were routed through the enlarged ASD
into the left atrium.VSD was closed with a Dacron patch
and right atrium was closed. Heart was deaired and cross
clamp released. Heart started beating in sinus rhythm (120
bpm), came off bypass with milrinone and noradrenaline.
Before heparin reversal, RA/PA oxygen step up was
checked withABG of RA& PAblood samples. There was
no significant step up of oxygen saturation from RA to
PA. Post bypass pressure in pulmonary artery was one
third of systemic pressure. Heparin was reversed with
protamine & surgery completed.
Patient was shifted to ICU, post operative analgesia
was maintained with fentanyl (10 mcg/hr) infusion. After
confirming that ABG, serum electrolytes including
calcium, chest X-ray, blood glucose were normal with no
147 Apollo Medicine, Vol. 8, No. 2, June 2011

3. Apollo Medicine, Vol. 8, No. 2, June 2011 148
Case Report
drainage from ICD’s - patient was fully rewarmed,
reversal given with neostigmine and atropine and patient
was weaned and extubation done 6 hours after surgery.
DISCUSSION
This is a very rare case of cyanotic congenital heart
disease with VSD, HAPVC of right pulmonary veins
draining near the coronary sinus into the right atrium,
ASD (R→L), PAH, TR, left atrial isomerism with left
superior vena cava draining into coronary sinus [1]. If a
lung infection develops in normal lung (e.g. left lung in
right HAPVC) then a picture similar to TAPVC with
severe desaturation and hypoxia would develop.
Anaesthetist plays an optimal role in managing such cases
wherein the pulmonary mechanics and respiratory care are
of utmost importance [2-3].
REFERENCES
1. Raisher BD,Grant JW, Martin TC, et al. Complete repair
of TAPVC in infancy, Journal of thoracic cardiovascular
surgery 1992;104: 443-448.
2. Sandeep Khanna, Minati choudhury, Usha Kiran.
TAPVC: post operative problems and management.
Indian Journal of Anaesthesia 2009; 53(1): 71-74.
3. David L Tomlinson, Hiroshi Goto, James C Graf,
Korasami Arakawa. Incidental discovery of persistent left
superior vena cava during cardiac surgery. Anesthesia
Analgesia, 1989; 69: 393-395.

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