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"I have a case for you": A parturient with decompensated CHF, s/p Mustard procedure for d-transposition of the great vessels, failing pacemaker and unreassuring fetal heart tones
Abstract Number: 135
Abstract Type: Case Report/Case Series
A Parturient, who has undergone correction for cardiac anomalies, can present challenges for the anesthesiologists. Understanding the physiological changes of pregnancy on the cardiac repair is paramount to ensuring the best outcome for mother and baby.
A 33 y.o. G2P1 EGA 33 2/7, s/p Mustard procedure presented with decompensated CHF & pneumonia. In 2000, a permanent pacemaker was implanted for severe bradycardia and pacemaker interrogation revealed LV lead & generator malfunction. In 2000, SVC & IVC stents were placed for stenosis & complicated by pulmonary embolism. Echo: RV ventricle severely hypertrophied, severely dilated & severely hypokinetic, severe tricuspid regurgitation, moderated pulmonary hypertension PAP 52 mmHg & EF 35%. Her current medications: Digoxin 0.25 mg, Furosemide 40 mg BID, azithromycin, rocephin & heparin 10,000 SQ qd (24 hours since last dose). A STAT section was called for unreassuring fetal heart tones. She was transported to the OR in LUD on 10L nonrebreather. Right radial a-line placed, additional 18 G PIV and Zoll pads placed & monitored. Positioned in left lateral decubitous, lumbar spine prepped & draped, L4-L5 interspace identified. After skin anesthesia an 18g Tuohy advanced, epidural space identified, needle bevel rotated parallel to the dura and intentional intrathecal (IT) catheter placed. Catheter secured & patient positioned in LUD. A total of 10 mg of hyperbaric bupivicaine, 20mcg fentanyl & 150mcg of duramorph titrated over 10 minutes, bilateral T6 dermatome level, & hemodynamic stability maintained throughout. C-section proceeded & neonate delivered (Apgar 7/9). The IT catheter removed in the PACU without event. The patient was discharged from PACU to the cardiac ICU. Hospital course was unremarkable, pacemaker left ventricular lead & generator replaced POD #2. She continued to be treated for her pneumonia. She was discharged in stable condition on POD 5.
In 1960, the mustard procedure was first performed to treat congenital transposition of the great vessels. The procedure creates an intra-arterial baffle using synthetic material to direct oxygenated pulmonary venous return into the right atrium. Blood travels from the right atrium into the right ventricle & then enters into the aorta (right ventricle=systemic ventricle). In 1985, the Mustard procedure was replaced by an anatomical correction. Reported complications to the Mustard repair are; baffle leaks, right heart failure, rhythm disturbances, obstruction of the intra-arterial venous pathway, sudden death1. Women who have undergone surgical correction of congenital heart anomalies may decompensate due to the additional physiological changes of pregnancy on the cardiopulmonary system. Spinal catheters provide quick access, a predictable block and the ability to titrate spinal dose to maintain hemodynamic stability.
1. Thor Cardiov Surg 2007