Case report Emergency cesarean section in a patient with Fontan circulation using an indwelling epidural catheter A. Ioscovich MD a,c,d, * , A. Briskin MD a,c,d , A. Fadeev MD a , S. Grisaru-Granovsky MD b , S. Halpern MD c,d a Department of Anesthesia, Shaare Zedek Medical Center, Jerusalem, Israel b Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel c Department of Anaesthesia, Sunnybrook and Women’s College Health Sciences Centre, Toronto, Ontario, Canada d University of Toronto, Toronto, Ontario, Canada Received 1 November 2005; revised 6 May 2006; accepted 8 May 2006 Abstract Management of parturients with a history of Fontan procedure requires careful monitoring of cardiovascular parameters and anticipation of potential complications. We describe potential pitfalls in a parturient with atriopulmonary Fontan circulation, who received epidural analgesia for labor and who later required emergency cesarean section. Low-dose local anesthetic in combination with meperidine provided excellent perioperative epidural analgesia and cardiovascular stability. Epidural analgesia during labor offered optimal pain relief and facilitated conversion to surgical anesthesia for an emergency cesarean section. D 2006 Elsevier Inc. All rights reserved. 1. Introduction The Fontan procedure, which allows venous blood to bypass various congenital cardiac lesions and flow to the lungs, is a palliative procedure for patients with certain congenital heart defects such as tricuspid valve atresia, a hypoplastic right ventricle, large ventriculoseptal defect (VSD), and pulmonary artery (PA) stenosis. The Fontan procedure dramatically reduces symptomatology and improves quality of life but does not return the cardiovascular physiology to normal [1,2]. As such, parturients who have had this procedure are at increased risk for morbidity and mortality during labor and delivery. Their management requires the anesthesiologist to carefully monitor cardiovas- cular parameters and anticipate problems. There are, to date, two case reports illustrating the anesthetic management of such patients in the literature [3,4]. In this case report, we describe a parturient with a history of Fontan procedure who received epidural analgesia for labor, which was converted subsequently into anesthesia for emergency cesarean section. 2. Case report A 25-year-old, 70-kg, 165-cm, primigravida parturient was admitted to our high-risk pregnancy unit at 36 weeks’ gestation for evaluation of intrauterine growth retardation. She was born with congenital heart defects that included tricuspid valve atresia, a hypoplastic right ventricle, large VSD, and PA stenosis. At the age of 8 years, she underwent 0952-8180/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2006.05.016 * Corresponding author. E-mail address: aioscovich@hotmail.com (A. Ioscovich). Keywords: Anesthesia; Obstetrical; Analgesia; Epidural; Labor; Catheterization; Indwelling epidural; Cesarean section; Fontan procedure Journal of Clinical Anesthesia (2006) 18, 631–634