Balancing act: SVR vs PVR balance for partially palliated hypoplastic left heart case report

Background: Advances in surgical and medical management have improved survival in complex congenital heart disease (CHD), and adult anesthesiologists increasingly encounter these patients in non-cardiac procedures. Understanding the physiologic impact of unique CHD cases and how anatomy alters optimal management is essential. Case Presentation: A 55-year-old woman with complex cyanotic CHD presented for removal and washout of a left lower extremity external fixator. Her cardiac anatomy included HLHS, dextrocardia, criss-cross atrioventricular valves, a large ventricular septal defect, two prior Blalock-Taussig (BT) shunts, an aortic shunt, and reduced EF. Notably, she had undergone only stage I palliation of HLHS. Baseline oxygen saturation was 75–85% on 4L nasal cannula. Comorbidities included HFrEF of the single ventricle, chronic hypoxia, hypertension, and a remote cerebrovascular accident (CVA). Conclusion: This case demonstrates the need for general anesthesiologists to understand the physiologic ramifications of CHD and recognize that anatomic variations may affect ideal management.