[General Anesthesia for Magnetic Navigation System-guided Catheter Ablation in a Patient with Persistent Atrial Tachycardia and an Extracardiac Total Cavopulmonary Connection].

Atrial arrhythmia is an important prognostic factor in patients undergoing the Fontan operation. Although catheter ablation is considered to be a curative treat- ment the anatomical constraints produced by extra- cardiac total cavopulmonary connection make it diffi- cult to insert catheters towards the right atrium. Mag- netic navigation systems enable safer catheter delivery to the target site in such cases. Catheter ablation was carried out under the guidance of a magnetic naviga- tion system after the Fontan conversion operation in a 39-year-old female patient with persistent atrial tachy- cardia for the first time in Japan. During a 3-hr period of atrial tachycardia (AT), the patient's hemodynamic status was severely compromised ; her systemic blood pressure fell below 80 mmHg, and her central venous pressure increased to 26 mmHg. After the termination of AT, the patient's hemodynamic status was normal- ized without any complications. The procedure was successful, and the patient was discharged as sched- uled. The number of catheter ablation procedures in patients with arrhythmia after the Fontan procedure is expected to increase as patients with complex congen- ital heart defects are surviving longer. It is important to clarify the issues associated with this procedure and establish a safe anesthetic management strategy based on hemodynamic data.

[A Case of EXIT (Ex-utero Intrapartum Treatment) in a Fetus with Prenatal Diagnosis of a Giant Cervical Tumor: Successful Airway Management but without Indication of Treatment for a Tumor].

The ex-utero intrapartum treatment (EXIT) is a rare procedure, and often comes as an emergency surgery. A careful preparation is crucial and a multidisciplinary team discussion during the prenatal period is necessary because it may be practically and ethically difficult to plan a surgical treatment for a fetus for EXIT. An elective caesarean section and EXIT for a fetus with a giant cervical tumor, which may cause airway obstruction and difficult intubation, were scheduled. The anesthesiologist tried oral intubation by direct laryngoscope; however, neither blade nor rigid bronchoscope insertion was impossible as a firm mass protruded in oral cavity from the left side. Tracheotomy was successfully performed and the airway was secured. As for maternal anesthesia, adequate uterine relaxation was obtained by inhalational agents and nitroglycerine. After ligation of the umbilical cord, anesthesia was maintained with propofol and fentanyl, and good uterine contraction was provided by infusion of oxytocin. The duration of EXIT was 44 minutes. The fetal tumor, containing both solid and cystic components, was 14 centimeters in diameter, and infiltrated into intracranial space. There was no indication of resection nor chemotherapy for the tumor. Palliative care was selected, and the neonate died forty days after birth.