Editorial

Change is the law of life and those who look only to the past or present are certain to miss the future.

This edition of the journal features excellent articles pertinent to the practice of congenital cardiothoracic anesthesia. Many of us are fortunate to provide anesthesia on an almost daily basis to patients with congenital heart disease (CHD). As these patients survive to adulthood and live productive lives, we are learning about some of the medical challenges they face. Congenital cardiac anesthesiologists are well positioned to help lead the future perioperative care of patients with complex CHD because of our insights into the physiology of their cardiac lesion and the how this may alter with comorbid conditions and anesthetic drugs. We should partner with our medical colleagues who care for patients with complex CHD and help develop innovative solutions to these medical challenges. Just as our patients grow up and change and face new challenges, so must we. Embracing these changes will be the future of congenital cardiac anesthesiology.

Patients with complex CHD usually have lifelong sequelae, and the first 3 articles explore some of these. The number of adults living with CHD far exceeds the number of children with CHD. The article by Nasr and Kussman ¹ reviews these data and the CHD-associated morbidity faced by survivors with CHD. The perioperative planning for these patients must include not only an understanding of their CHD and current physiological status but also any additional “adult” comorbidity such as coronary artery disease. As patients with complex CHD survive into adulthood, we must learn from our patients and study the new problems they present with. One of the issues faced by patients with a single ventricle circulation is right ventricular heart failure. This is reviewed in the article by Riveros and Riveros-Perez, ² who explain how the right ventricle is not adapted for a lifetime of providing cardiac output to the systemic vasculature in patients with Fontan physiology. As more children with Fontan physiology survive to adulthood, new challenges are being presented to clinicians. The parturient with Fontan physiology provides unique challenges to the anesthesiologists. Tiouririne et al ³ present a review of 27 case reports of the peripartum management of parturients with Fontan circulation and the challenges faced by the physiological changes of pregnancy in addition to the complex single ventricle physiology. The early data are encouraging for women with Fontan physiology who want to have children. With appropriate peripartum care, it is possible for them to have healthy children safely, albeit with some increase in the risk of complications.

The next 4 articles center on the perioperative management of patients with transposition of the great arteries (TGA). Files and Arya ⁴ provide an introduction to TGA in their article, reviewing the imaging and physiology of this congenital heart lesion. This sets the stage for the surgeons Hermsen and Chen ⁵ to review the surgical considerations when repairing TGA. The surgical advancements in the repair of this lesion from the initial “atrial switch” of Senning and Mustard, to the current “arterial switch,” first performed in Jatene in 1975, are fascinating. It also serves to remind us how the care of patients with CHD continues to change. As perioperative physicians we must not only keep up to date with these changes but also be involved in the long-term follow-up of patients with CHD, so that when they present for future cardiac or noncardiac surgery later in life we are able to provide excellent anesthesia care. These issues are highlighted in the review by Latham et al, ⁶ who focus not only on the initial anesthetic management of neonatal patients with TGA but also on the management of these same patients later in life. However, even with the best available care, some patients with TGA will progress to end-stage heart failure and may be considered for heart transplantation. Sehgal et al ⁷ present a case report that highlights the challenges of bridging these patients to transplantation with ventricular assist devices.

The final 2 articles focus on pediatric anesthesia but both conditions under consideration are not unique to children—mediastinal masses and myocardial infarction. There is one anesthetic scenario that will make even an experienced pediatric anesthesiologist pause for thought and perhaps feel anxious about the challenge ahead, and that is a child presenting with a newly diagnosed anterior mediastinal mass. Pearson and Tan ⁸ provide a comprehensive review of this topic. Their article examines the important investigations, risk stratification, and team approach that is necessary to safely care for these patients. Reading this article may help alleviate some of the anxiety felt by an anesthesia provider in this situation! Myocardial infarction is common in adults but rare in children. Kawasaki’s disease in a poorly understood vasculitis and a leading cause of acquired heart disease in children. It can cause coronary artery aneurysms, which can develop thrombosis resulting in subsequent myocardial infarction. Jone et al ⁹ present a case report of this scenario and discuss the management pathway for treating myocardial infarction in children with Kawasaki’s disease and propose that combination therapy may be the best approach.

Finally, in a letter to the editor, Ravindra ¹⁰ proposes a simple monitoring solution to help guide the surgical resection of a thoracic inlet neurofibroma. Many times, it is the simplest approaches that provide the best outcomes.