Version June 2024
| CHD lesion | Heart rate | Left ventricular afterload | Pulmonary vascular resistance | Physiologic concepts |
| Left-to-right shunt lesions (ASD, VSD, PDA) | Maintain normal HR (60 to 100 bpm) | Maintain normal to slightly low SVR | Maintain normal to slightly high PVR; avoid hyperoxia or hypocarbia | Maintain a normal to low SVR and avoid increases in SVR to avoid increased left-to-right shunting. (However, vasodilation with very low SVR is avoided in patients with a PDA, as this may result in diastolic run-off that compromises coronary perfusion.) Maintain normal to slightly high PVR. Hyperoxia and hyperventilation are avoided to prevent decreases in PVR which may increase left-to-right shunting. |
| Pulmonic valve regurgitation | Maintain normal to fast HR (80 to 100 bpm) | Maintain normal SVR | Maintain normal to low PVR; increase FiO2; mild hyperventilation; avoid hypoxia, hypercarbia, acidosis | A faster HR minimizes regurgitant volume through an insufficient valve. Maintain a normal to low PVR to facilitate forward flow in the pulmonary arterial circulation. Increasing FiO2 and mild hyperventilation to a PaCO2 of approximately 30 to 35 mmHg will lower PVR. Avoid hypoxia, hypercarbia, and acidosis to prevent increases in PVR. |
| Tetralogy of Fallot or Pulmonic valve stenosis | Maintain normal to slow HR (60 to 80 bpm) | Maintain normal to elevated SVR | Maintain normal to low PVR; increase FiO2; mild hyperventilation; avoid hypoxia, hypercarbia, acidosis | A normal to slow HR is maintained when a dynamic RVOT obstruction is present since tachycardia increases dynamic RVOT obstruction, thereby increasing right-to-left shunting. Tachycardia also reduces time in diastole which reduces coronary perfusion such that myocardial ischemia may develop. Maintain a normal to elevated SVR to decrease right-to-left shunting. Maintain a normal to low PVR to decrease right-to-left shunting. Increasing FiO2 and mild hyperventilation to a PaCO2 of approximately 30 to 35 mmHg will lower PVR. Avoid hypoxia, hypercarbia, and acidosis. |
| Coarctation of the aorta | Maintain normal HR (60 to 100 bpm) | Maintain BP in lower extremity near baseline values; avoid large increases in upper extremity BP | Maintain normal PVR | BP in both arms (or in only the right arm) will generally be relatively high because both (or only the right) axillary arteries are proximal to the coarctation; lower extremity BP will be lower because the femoral arteries are distal to the coarctation. Maintain both upper and lower extremity BPs near baseline values. |
| Sinus of Valsalva aneurysm or fistula | Maintain normal HR (60 to 100 bpm) | Maintain normal SVR | Maintain normal to slightly high PVR | Maintain normal HR and normal SVR to support coronary perfusion, particularly in patients with coronary compression or evidence of myocardial ischemia. Maintain a normal to slightly high PVR to decrease left-to-right shunting if a fistula has formed. |
| Anomalous origin of a coronary artery | Maintain normal to slow HR (60 to 80 bpm) | Maintain normal SVR | Maintain normal to slightly high PVR | Maintain normal to slow HR and normal SVR to support coronary perfusion, particularly in patients with evidence of myocardial ischemia. However, in patients with an anomalous coronary artery origin from the pulmonary artery with collateral circulation from a normally arising coronary artery, BP should not be so high as to increase aortic-to-PA shunting. Maintain normal to slightly high PVR to reduce aortic-to-PA shunting. |
| Ebstein anomaly or Tricuspid regurgitation or stenosis | HR goal depends on TV: maintain normal to slow HR for stenosis (60 to 80 bpm) and normal to high HR for insufficiency (80 to 100 bpm) | Maintain normal SVR | Maintain normal to low PVR | Onset of action for intravenous medications may be delayed due to venous "pooling" in the large right atrium. Supraventricular tachycardias are very common during anesthesia induction and must be treated promptly. Vasoactive support for RV function is typically necessary in Ebstein anomaly. Normal to low PVR facilitates forward flow in the pulmonary arterial circulation. Avoid hypoxia, hypercarbia, and acidosis to prevent increases in PVR which may exacerbate RV dysfunction. |
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