Three-Dimensional Transesophageal Echocardiography and Management of a Patient with an Anomalous Left Coronary Artery Undergoing Cesarean Section
Abstract Number: 65
Abstract Type: Case Report/Case Series
Introduction: Anomalous left coronary artery arising from the pulmonary artery (ALCAPA Syndrome) is a rare and potentially life threatening disease with few patients living to adulthood. A patient with probable ALCAPA presented for cesarean delivery. Three-dimensional transesophageal echocardiography (3DTEE) was utilized as a hemodynamic monitor, guided fluid and vasoactive therapy, and conclusively mapped the patient's coronary anatomy, establishing her diagnosis.
Case: A 21 year-old G4P3 patient with three previous cesarean sections presented for repeat cesarean section complaining of dyspnea and orthopnea. The patient had prior echocardiograms demonstrating no obvious origin of the left coronary artery, and therefore suspicious for ALCAPA, but had declined cardiac catheterization for definitive diagnosis. The left ventricle was dilated with mild systolic dysfunction.
After placing standard monitors and a radial arterial catheter, general anesthesia was induced with sodium thiopental and fentanyl and maintained with isoflurane. Tracheal intubation was facilitated with succinylcholine, and nicardepine infused as necessary to control hemodynamics. Real-time 3DTEE was used intraoperatively to guide fluid administration and the use of vasoactive agents. 3DTEE also clearly depicted an anomalous coronary vessel arising from the root of the pulmonary artery, and the absence of a vessel at the usual site of left coronary artery origin. The patient had an uneventful anesthetic with well-controlled hemodynamics and uncomplicated delivery, and was discharged from the hospital with a healthy child three days later.
Discussion: Definitive diagnosis of ALCAPA is critical, since this disease is generally lethal if not corrected. 3DTEE was able to clearly identify an anomalous vessel arising from the pulmonary artery in this patient. Additionally, 3D imaging allows the heart to be depicted from any viewing angle, free of the restrictions of standard imaging planes. This so-called "anyplane" imaging allowed a virtual examination of the entire aortic root not before possible with traditional 2D echocardiography, ultimately demonstrating the absence of a normal left coronary artery at its usual site of origin. 3DTEE may become a useful tool in obstetric patients with complex cardiac anomalies for both definitive diagnosis and peri-partum anesthetic management.