Cardiac Failure in a Trisomy 9 Patient Undergoing Anesthesia: A Case Report

Abstract

A 27-year-old female with Trisomy 9 mosaicism presented to Children's Hospital Colorado for outpatient dental surgery under general anesthesia. The patient's past medical history was also significant for premature birth, gastroesophageal reflux, scoliosis and kyphosis, obesity, and developmental delay. Per her mother's report, the patient had no cardiac issues. She had undergone multiple previous general anesthetics, some of which documented respiratory complications such as laryngospasm, bronchospasm, and possible aspiration. During this anesthetic, the patient became hypotensive on induction, with sluggish response to intravenous fluids, glycopyrrolate, and ephedrine. Her electrocardiogram demonstrated what appeared to be left bundle branch block at baseline, with possible ST segment changes after induction. Due to her abnormal reaction to the induction and subsequent treatment for hypotension, an echocardiogram was performed. The patient was found to have an ejection fraction of 25%-30%. The anesthetic was uneventful for the remainder of the procedure, and following recovery, the patient was admitted by the heart failure team for further care.

Congenital hydrocephalus in a trisomy 9p gained child: a case report

“…The recent case report by Kasper et al (2020) confirms the difficulties in the treatment of trisomy 9p associated with CSF hypersecretion, and the authors advocate placement of a VA shunt in this condition [7]. It is, however, estimated that 40-60% of the 9p tri-and tetrasomy cohort have coexisting heart disease [1,3,8,9,13,15]. Placement of a VA shunt in these patients, as secondarily performed in our case [1], may accordingly be less optimal, necessitating VA shunt removal and subsequent choroid plexus coagulation and/or pharmacological therapy with acetazolamide and furosemide to diminish daily CSF production to volumes that allow proper VP shunting [4-7, 11, 15].…”

“…In children with trisomy 9p, congenital hydrocephalus due to choroid plexus hyperplasia is well documented alongside a variety of phenotypical manifestations including craniofacial dysmorphic features, growth retardation, mental retardation, hand and foot anomalies [1,3,8,9,16], and congenital heart diseases including ventricular septal defect (VSD), atrial septal defect (ASD), hypoplastic left heart, and cardiomyopathy [3,8,9,13,14,16].…”

“…Optional but rarely used treatment options such as ventriculoatrial (VA) shunt, choroid plexus coagulation, and pharmacological treatment may thus be needed to control choroid plexus hyperplasia-derived hydrocephalus in trisomy 9p [1, 4-15, 15, 16]. However, the known risk of VA shunt-associated cardiovascular complications such as endocarditis, heart failure, intraatrial thrombus, and pulmonary hypertension may exclude this treatment modality in trisomy 9p patients with cooccurring congenital heart disease [4,5,8,9,13,14,16], as illustrated by the current case report.…”

Major relationships of tooth extraction in patients with cardiovascular diseases: a concise systematic review

“…Likewise, vasoconstrictors should be welladjusted. Adrenaline, for example, has a maximum recommended dose of 0.2mg, while noradrenaline is 0.34mg per session [9,10]. The use of anesthetic prilocaine should be carefully monitored because doses above 600 mg may cause episodes of methemoglobinemia (Meta-hemoglobin is a form of hemoglobin protein, in which the iron in the heme group is in the Fe 3+ state and not in Fe 2+ of normal hemoglobin In this disorder, iron atoms in the form of ferric ions lose the ability to release oxygen to tissues causing episodes of tachycardia, cyanosis, dyspnea, fatigue, headache, vomiting, and dizziness, and may progress to coma and death.…”

“…Thus, the acquired ones are the most frequent in the routine of a dental practice, so the dentist should be able to attend to those patients who need special care, regarding the correct use of medications due to the risk of drug interactions, the type of local anesthetic to be used and the management of patients who use anticoagulant therapy [1,9].…”