INTRODUCTION
Ebstein's anomaly is rare congenital heart disease ,in which 
there is downward displacement and elongation of tricuspid 
valve with poor contractile right ventricle ,characterized by 
dysplastic abnormalities of both basal and free attachments 
of tricuspid valve leaets resulting in tricuspid regurgitation. It 
is frequently associated with intracardiac shunting , 
pulmonary hypertension,cardiac dysrhythmias, cyanosis, 
congestive heart failure and sudden collapse are the most 
common causes of death . The  incidence in general 
population is 1:10,000 and no sex difference.

Case report:
A 50 years old male patient moderately built presented with 
varicose veins of left leg. He had chest pain ,easy  
fatigability,exertional dyspnoea since 25years.He is the 
known case of ebstein's  anomaly, which was diagnosed in 
jayadeva hospital 10 years back. On examination he had 
regular pulse rate of 92bpm and blood pressure of 100/60mm 
of Hg with grade 2 clubbing. There was no signs of cardiac 
failure.On auscultation of heart sounds ,a pansystolic murmur 
was audible in mitral and tricuspid areas.2D ECHO shows 
ebsteins anomaly, severe tricuspid regurgitation, patent 
foramen ovale R>L Shunt with ejection fraction 60% .ECG 
shows low voltage complexes and tall p waves in lead 
2,AVR,AVF with  rbbb . chest x ray shows cardiomegaly with 
CT ratio of 11:17, hes on Tablet frusilac (frusemide 20mgand 
spirinoactone50mg) and Tablet daion 500mg,routine 
bloodinvestigations were within normal limits , epidural 
anaesthesia was planned for trendelenberg surgery. Tablet 
Pantoprazole 40mg and Tablet anxit 0.5mg was given the 
previous day and ranitidine 150mg,Ttablet frusilac was 
continued on the day of surgery. IV line was secured with 18G 
canula ,antibiotic prophylaxis for infective endocarditis was 
given ( inj ampicilin 2gm and gentamycin 80mg),routine 
monitoring was done .in the sitting posture under aseptic 
precautions  epidural anaesthesia achieved by injecting 10m 
lof 0.25% of bupivacaine with 75mcg fentanyl at L3-L4 Epidural 
space with loss of resistance technique and hanging drop test, 
epidural catheter passed and drug is given. No intaoperatve fall 
in blood pressure . BP was maintained 100/60 mmof Hg which 
was maintained with ephedrine infusion, haemodynamics were 
maintained, surgery was lasted for 44 minutes. Post op 
analgesia given with 0.0625% of 8cc bupivacaine and advised 
for low molecular weight heparin and early ambulation was 
advised to prevent thromboembolic episodes.

FIGURE 1: Clubbing is present grade 2. 

FIGURE 2:ECG showing tall Himalayan p wavesin lead 
II,III,avF  with left axis deviation.

FIGURE 3:ECG showing RBBB with tall p waves.

TABLE 1: These are ECHO reports of the patient.

FIGURE 4:CHEST X RAY PA view showing cardiomegaly, 
BOX  Shaped heart.

DISCUSSION
The prime consideration in managing our case was to 
maintain haemodynamic stability ,maintaining preload and 
afterload and prevention of supraventricular and ventricular 
arrhythmias during and in the post operative period .the case 
study shows the safety of low dose epidural with ebsteins 
anamoly with severe tricuspid regurgitation.the advantages 
of epidural anaesthesia are minimal intravascular volume 

ANAESTHETIC MANAGEMENT OF A CASE OF VARICOSE VEINS 
SURGERY,IN A PATIENT WITH EBSTEIN'S ANOMALY.

Original Research Paper

Dr Mahalakshmi M 
Baddi

Anaesthesiology

KEYWORDS : 

VOLUME-9, ISSUE-1, JANUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Dr Nirmala B C* *Corresponding Author

2009 2014 2019 

Congenital heart 
disease 

Congenital heart 
disease 

Congenital heart 
disease 

Situs  solitus . Situs  solitus. Situs  solitus.

Ebstein's  anamoly. Ebsteins  anamoly. Ebsteins  anamoly 

Mild tricuspid 
regurgitation.
Ostium secundum 
 ASD
 R>L Shunt

Severe tricuspid 
regurgitation ( 
grade 3).
ASD
 R>L Shunt 

Severe tricuspid 
regurgitation .

PFO
 R>L Shunt 

Normal LV 
function(60%) 

Normal LV 
function(65%) 

Normal LV 
function(60%) 

14 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS



shi f t ,  decreased cathecolamine levels  and good 
postoperative analgesia.low  concentrationof 0.25% of 
bupivacaine has low cardiac and systemic toxicity. fentanyl 
75mcg helps in attenuating the hormonal responses to 
stresses associated with surgery

CONCLUSION
A thorough understanding of the pathophysiology of this 
condition is essential for the successful anaesthetic 
management in ebsteins anamoly and anaesthetic 
techniquechoosen should be individualized based on cardiac 
status , type of surgery, site of surgery and also the duration of 
surgery, our experience shows that , a low dose epidural 
should be considered as one of option available in ebsteins 
anomaly for lower limb surgeries.

VOLUME-9, ISSUE-1, JANUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

  X 15GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS