Defying Surgical Contraindication: High-Stakes Anesthesia Management Enables Curative Thyroid Cancer Resection in a Patient with Complex Congenital Heart Disease

Case Introduction

This patient simultaneously carried two diagnoses: papillary thyroid cancer with suspected lymph node metastasis and severe complex congenital heart disease. Her cardiac anomalies included a single atrium, single ventricle (right ventricular morphology), transposition of the great arteries, and severe pulmonary stenosis — resulting in chronic hypoxemia. After being evaluated and rejected by multiple hospitals as too high-risk for any surgical intervention under general anesthesia, she arrived at Beijing Arion Cancer Hospital seeking a definitive answer.

The fundamental challenge was stark: thyroidectomy requires general anesthesia, but this patient's unique cardiac anatomy and profoundly abnormal hemodynamics meant that intraoperative malignant arrhythmia, acute heart failure, and severe deoxygenation were not merely theoretical risks — they represented life-threatening probabilities. Through comprehensive multidisciplinary evaluation, precise perioperative planning, and meticulously executed anesthesia management, Arion's team completed this high-stakes operation successfully.

I. Patient Profile: Baseline Status and Core Challenges

Patient Demographics

Patient: Female, 46 years old.

Chief Complaint: Diagnosed thyroid cancer with suspicious lymph node metastasis for over one month.

Congenital Heart Disease Profile

Previous cardiac catheterization confirmed:

• Dextrocardia (situs solitus with right-sided heart)
• Single atrium (common atrium)
• Single ventricle, right ventricular morphology
• Pulmonary valve stenosis, severe subvalvular narrowing
• Transposition of the great arteries (both aorta and pulmonary artery arising from the anatomical right ventricle)
• Fused left and right pulmonary arteries; left pulmonary artery shows aneurysmal dilation
• Pulmonary artery pressure: 32/16 mmHg

Functional Baseline

Parameter	Value	Significance
Pulse oximetry (SpO&sub2;)	77%–81%	Chronic hypoxemia baseline
Functional capacity	Able to climb 3 flights of stairs (confirmed by anesthesiologist)	Indicates preserved compensatory reserve
Cyanosis	Lip cyanosis present	Visible sign of chronic low oxygen saturation
Obstetric history	One prior vaginal delivery (successful)	Previously tolerated physiological stress

The Clinical Dilemma

Papillary thyroid cancer is a surgically curable disease when completely resected. However, this patient's functional univentricular physiology created an unprecedented set of perioperative hazards:

• Hemodynamic fragility: With both great vessels originating from a single systemic ventricle, coronary and systemic perfusion depend entirely on maintaining a delicate balance between systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR).
• Arrhythmogenic substrate: The common atrium creates an enormous electrical circuit prone to re-entrant tachyarrhythmias under sympathetic stress.
• Hypoxemic risk: Baseline SpO&sub2; of 77–81% leaves minimal reserve before critical desaturation occurs during induction or airway manipulation.
• Pulmonary vulnerability: Severe pulmonary stenosis means any increase in PVR (from hypoventilation, acidosis, or hypoxia) could precipitously reduce pulmonary blood flow and worsen cyanosis.

II. Multidisciplinary Team Assembly: Crafting the Perioperative Strategy

MDT Composition

A specialized task force was convened comprising the following departments:

Department	Role in Perioperative Planning
Gastrointestinal Tumor Center	Surgical planning for total thyroidectomy with unilateral neck dissection; minimizing operative time while ensuring oncologic completeness.
Anesthesiology Center	Core leadership role: designing the entire perioperative anesthesia protocol, from preoperative optimization to postoperative recovery.
Cardiology Department	Comprehensive functional assessment of the univentricular circulation; guidance on hemodynamic targets and vasoactive drug selection.
Intensive Care Unit (ICU)	Post-operative monitoring plan; readiness for potential cardiopulmonary complications.
Ultrasound / Radiology	Preoperative imaging review confirming cardiac anatomy and thyroid/neck tumor extent.

Treatment Pathway Analysis

The patient had already visited multiple institutions, each declining to operate due to the perceived prohibitive risk of general anesthesia in a patient with a functional single ventricle. Her psychological state was one of profound anxiety mixed with a desperate desire for definitive treatment.

Key considerations guiding the MDT decision:

• Thyroid papillary carcinoma is highly amenable to surgical cure — delaying treatment allows potential lymph node progression.
• Despite her complex anatomy, the patient demonstrated meaningful functional capacity (climbing 3 flights), suggesting adequate physiological compensation.
• The primary goal shifted from "whether to operate" to "how to operate safely."
• Operative time must be minimized to reduce cumulative hemodynamic stress.

III. The Anesthesia Protocol: A Six-Pillar Strategy

After extensive deliberation, the team finalized the following perioperative anesthesia management plan organized around six core pillars:

Pillar 1: Preoperative Preparation & Psychological Support

• Thorough informed consent process addressing all realistic risks transparently.
• Active communication to mitigate the patient's severe preoperative anxiety — recognized as an independent trigger for sympathetic surge and arrhythmogenesis.
• Confirmation of functional capacity via supervised stair-climbing test performed alongside the anesthesiologist.

Pillar 2: Intraoperative Analgesia & Stress Attenuation

• Multimodal analgesic approach to minimize intraoperative stress response.
• Ropivacaine local infiltration at the incision site before skin incision to reduce intraoperative opioid requirements.
• Maintenance of stable internal milieu throughout the procedure.

Pillar 3: Hemodynamic Stabilization

• Maintenance of appropriate afterload (SVR) to preserve systemic perfusion pressure.
• Avoidance of excessive PVR elevation through strict prevention of hypoxia, acidosis, and hypercarbia.
• Readiness to administer pulmonary vasodilators if needed.
• Continuous infusion of norepinephrine and dobutamine to maintain mean arterial pressure within ±10% of baseline values.

Pillar 4: Rhythm Preservation

• Primary objective: maintain sinus rhythm throughout.
• Vigilant monitoring for early signs of ectopy or re-entrant tachycardia.
• Immediate availability of antiarrhythmic agents and defibrillation equipment.

Pillar 5: Protective Lung Ventilation

• Inspired oxygen concentration: 50% (air-oxygen mixture) — deliberately avoiding 100% O&sub2; to prevent absorption atelectasis and oxidative injury while maintaining acceptable oxygenation.
• Tidal volume: 6 mL/kg (low-tidal-volume protective strategy).
• Respiratory rate: 12 breaths/min.
• Intraoperative SpO&sub2; range maintained at 75%–85% (consistent with the patient's chronic baseline).

Pillar 6: Postoperative Multi-Modal Analgesia

• Planned transition to multimodal analgesia immediately upon emergence.
• Target: smooth emergence with minimal sympathetic activation.

IV. Intraoperative Execution: Step-by-Step

Preoperative Diagnoses (Complete List)

1. Malignant neoplasm of thyroid gland
2. Secondary malignant neoplasm of cervical lymph nodes (suspected)
3. Dextrocardia
4. Congenital heart disease: functional single ventricle (right ventricular type)
5. Atrial septal defect / Common atrium (single atrium)
6. Pulmonary valve stenosis (severe)
7. Congenital tricuspid regurgitation (non-Ebstein type)
8. Type I respiratory failure (hypoxemic)
9. Hyperlactatemia

Planned Procedure

Total bilateral thyroidectomy + unilateral cervical lymph node dissection.

Anesthetic Induction

Slow-sequence induction technique was employed to minimize hemodynamic perturbation:

• Sequential intravenous administration: midazolam → sufentanil (slow fractionated injection) → etomidate → rocuronium.
• Tracheal surface anesthesia applied before laryngoscopy.
• Video laryngoscope-guided endotracheal intubation — minimizing airway stimulation duration.

Anesthetic Maintenance

• Inhaled: sevoflurane.
• Intravenous boluses: sufentanil and rocuronium administered intermittently.
• Continuous infusion: remifentanil for steady-state analgesia.
• BIS target: 40–60 (adequate hypnotic depth).
• Vasoactive support: Continuous norepinephrine + dobutamine infusion throughout.

Surgical Details

Parameter	Value
Procedure performed	Total bilateral thyroidectomy + unilateral neck lymph node dissection + regional lymphadenectomy + recurrent laryngeal nerve exploration + parathyroid autotransplantation
Total operative time	3 hours 03 minutes
Intraoperative crystalloid	2,000 mL
Estimated blood loss	100 mL
Urine output	100 mL

Emergence & Recovery

• 30 minutes before conclusion: Flurbiprofen axetil administered for preemptive analgesia.
• At wound closure: All anesthetic agents discontinued; sugammadex administered for rapid neuromuscular reversal.
• Extubation: Successfully achieved in the operating room.
• Pain score at extubation (VAS): 1/10 (excellent).
• Post-operative destination: Transferred to ICU for close monitoring.

V. Postoperative Course & Outcome

Timepoint	Status
Day 0 (immediate post-op)	Transferred to ICU; stable hemodynamics
Day 1	Transferred to general ward
Day 2	Discharged home with good recovery
1-month follow-up	No cardiac-related complaints
Pathology result	Papillary thyroid carcinoma; 7/18 lymph nodes positive for metastatic carcinoma; extracapsular extension present in some nodes
Adjuvant therapy	Iodine-131 radioiodine therapy administered at 1 month post-surgery
Current status	On regular surveillance follow-up schedule

VI. Key Clinical Insights

Insight 1: Functional Single Ventricle Demands a Fundamentally Different Anesthetic Approach

Patients with univentricular physiology cannot be managed using standard cardiac anesthesia algorithms. The absence of a separate pulmonary circulation means that SVR and PVR are in direct competition for the same ventricular output. Any maneuver that increases PVR (hypoventilation, acidosis, hypoxia, hypercapnia, high mean airway pressures) directly steals blood flow from the systemic circulation. Conversely, excessive reduction in SVR can cause systemic hypotension and coronary hypoperfusion. The anesthesiologist must walk a continuous tightrope between these competing forces.

Insight 2: Preoperative Functional Assessment Is Non-Negotiable

The supervised stair-climbing test performed by the anesthesiologist provided crucial real-world data about this patient's cardiopulmonary reserve that no echocardiogram or cardiac MRI could fully capture. For complex ACHD patients, functional testing should be a mandatory component of preoperative risk stratification.

Insight 3: Communication Is a Therapeutic Intervention

This patient's extreme anxiety was itself a physiological threat — catecholamine surges from fear could precipitate arrhythmias or increase myocardial oxygen demand beyond what her compromised circulation could supply. Every MDT member invested significant time in empathetic, detailed conversation with the patient and family, building the trust necessary for her to enter the operating room with manageable anxiety levels rather than terror.

Insight 4: MDT Is Not Optional — It Is the Standard of Care

No single specialist could have managed this case safely. The surgeon needed the anesthesiologist's hemodynamic expertise; the anesthesiologist needed the cardiologist's understanding of univentricular pathophysiology; everyone needed the ICU team's safety net. This case exemplifies how true MDT integration — not just sequential consultations but genuine collaborative planning — transforms "inoperable" into "operable with caution."

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Expert Commentary

Prof. Yu Chunhua

Department of Anesthesiology, Peking Union Medical College Hospital (PUMCH), Beijing

This is a genuinely challenging case whose management fully demonstrates the central value of the multidisciplinary team (MDT) framework in navigating complex clinical scenarios.

Perioperative management of non-cardiac surgery in adults with congenital heart disease (ACHD) is inherently more demanding than in the general population, with difficulty level determined by the specific cardiac anatomy, the patient's current pathophysiological state, and the inherent risks of the planned surgery itself.

This patient's constellation of cardiac anomalies — single atrium, single ventricle (right ventricular morphology), double-outlet right ventricle, and severe pulmonary valve stenosis — represents an exceptionally high-risk substrate. Currently, there are no established anesthesia management guidelines specifically for this anatomical configuration within China. The anesthesia team relied primarily on domestic and international case reports to distill experience and design their approach.

Throughout management, the anesthesiologist must focus on three core elements: the complexity of the cardiac lesion, the patient's current physiological status, and the intrinsic risk of the surgical procedure. Only by integrating these three dimensions can accurate risk stratification, perioperative state optimization, and truly individualized anesthesia strategy be achieved.

Additionally, the anesthesiologist must remain vigilant regarding non-cardiac comorbidities commonly encountered in ACHD patients, including restrictive lung disease, renal dysfunction, hepatic impairment, neurological sequelae, and hematological abnormalities such as iron-deficiency anemia, secondary erythrocytosis, and coagulopathy with bleeding or thrombotic tendencies.

Facing such a complex clinical landscape, high-quality interdisciplinary collaboration and communication between the anesthesiologist and the broader MDT team constitutes the foundation of optimized perioperative management. In this process, the MDT team needs not only solid pathophysiological knowledge to dissect the clinical picture but also a strong sense of professional responsibility and moral courage — the willingness to seek viable pathways for patients even amid formidable risk.

Furthermore, given this patient's prolonged medical odyssey and deep-seated fear of her conditions, significant anxiety was inevitable. Gentle, thorough communication from every MDT member with the patient and her family was essential for earning trust, understanding, and cooperation. The robust trust established through continuous communication — among team members and between clinicians and patient alike — was a critical factor ensuring the entire diagnostic and therapeutic process proceeded smoothly.

Ultimately, the MDT team demonstrated courage, embraced the challenge, collaborated seamlessly, and completed every step of care successfully. This case once again proves that in extremely complex ACHD patients, anesthesiology-centered MDT with precision collaboration and full-course individualized management is the key to breaking through surgical contraindications and improving long-term outcomes.

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