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The population of children undergoing successful surgery for congenital heart disease (CHD) continues to increase. Increasing number of patients with a Fontan circulation is reaching adulthood and requiring anesthesia for noncardiac surgeries. We anesthetized a patient with a Fontan circulation (9 years old) for giant internal carotid-ophthalmic artery aneurysm trapping. There was a difficulty in cannulating internal jugular vein for measuring central venous pressure because of abnormal collateral arteries around the internal jugular vein. Central venous pressure of around 15 mmHg seemed appropriate to keep good hemodynamic condition during this surgery. In this condition, cerebral cortex was not edematous. Careful management of circulatory volume stabilized hemodynamic state. However, when heart rate decreased below 75, ectopic atrial rhythm occured. Anesthetic time was 13 hr and 40 min. The patient was extubated in the operating room. We have to take into consideration that there are anatomical abnormalities and arrhythmia in the patients with a Fontan circulation.

The advancement of surgical and anesthetic techniques reduced cardiac morbidity and mortality. As a result, the attention has been focused on the perioperative cerebral complication, which contribute to more than 20% of perioperative deaths. Cognitive dysfunction is associated with increased medical costs, decreaged quality of life, and mortality. However, the incidence of cognitive dysfunction has a wide variety due to methodological variations in evaluating cognitive dysfunction, showing the complexity of cognitive dysfunction. The score of cognitive test can include learning effect and natural decline of cognitive dysfunction in elderly population. The research including the control group seems to overcome these issues, but still remains to have problems. Further, patients with cardiac disease have comorbid factors to induce postoperative sequelae compared to healthy population. We describe these issues which require continued researches.

A 14-yr-old boy with hypertrophic obstructive cardiomyopathy, undergoing percutaneous transluminal septal myocardial ablation suffered dissection of the left main coronary artery during the procedure. Sixty minutes after absolute ethanol administration, he was transferred to the operating room for emergency coronary artery bypass grafting, mitral valve replacement and cardiomyectomy. Transesophageal echocardiography (TEE) findings after the induction of anesthesia were: general hypokinesis, mitral regurgitation 1+, left ventricular outflow tract pressure gradient of 11 mmHg and no blood flow in the left anterior descending coronary artery. On aorta declamping, ECG showed ventricular fibrillation and ventricular tachycardia, and the sinus rhythm was restored after 100 mg lidocaine i.v. and DC conversion. TEE revealed severe hypokinesis in antero-septal and hypokinesis in posterolateral wall, respectively. Since supraventricular tachycardia (HR 130 140 bpm) disabled the intraaortic balloon pump (IABP) synchronization, HR was maintained 90-100 bpm with landiolol hydrochloride (10-40 micrograms x kg(-1) min(-1)) and synchronization was obtained. Systolic BP was maintained 90-120 mmHg with norepinephrine (0.2-0.3 micrograms x kg(-1) x min(-1)) and the patient could be successfully weaned from CPB with cardiac index 2.0 and mixed venous oxygen saturation 59%. On the 2nd postoperative day (POD), he was weaned from IABP and ventilator. On the 6 th POD, he was discharged from the ICU.