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Anesthetic management of a parturient with severe aortic valve stenosis: a case report and literature review
Abstract Number: 252
Abstract Type: Case Report/Case Series
Purpose: Anesthetic management of obstetric patients with severe aortic valve stenosis (AS) is challenging and controversial. We discuss both anesthetic techniques for two different cesarean deliveries (CDs) in the same patient with worsening AS and present a literature review.
Clinical features: The patient gave written informed consent for publication of this information. An adult primiparous patient presented at 28 wks gestation. She had a bicuspid aortic valve with an area of 0.80 cm2 and a mean systolic gradient of 50 mmHg. She complained of mild dyspnea. One week later, she developed severe preeclampsia. After multidisciplinary discussion, it was decided to proceed with urgent CD with epidural anesthesia and invasive blood pressure monitoring. Standard monitors were applied and a radial artery catheter was placed. An epidural catheter was placed and the patient was positioned supine with uterine displacement. Ropivacaine 0.75% was administered incrementally until a bilateral T4 sensory block was reached. The patient remained stable and surgery proceeded uneventfully. Preservative free morphine 3.5 mg was administered via the epidural catheter. The patient was observed for 36h post delivery in the step up unit. She was discharged 3 days later.
Four years later, the patient became pregnant again and complained of dyspnea at 28 wks gestation. The echocardiogram showed an aortic valve area of 0.59 cm2 and mean systolic gradient of 67 mmHg. After a multidisciplinary conference, it was decided to proceed with general anesthesia for elective CD in the cardiac OR. At 36 wks gestation, the patient was brought to the OR. Non-invasive (including BIS monitor) and invasive monitors (radial arterial line, central line) were placed. General anesthesia was induced with remifentanil, etomidate, and succinylcholine. The patient was intubated and a TEE probe was placed. Anesthesia was maintained with remifentanil, N2O, and desflurane. Surgery proceeded uneventfully she remained hemodynamically stable. A healthy baby was born. The patient was given intravenous morphine, along with bilateral transversus abdominis plane blocks (40 ml total ropivacaine 0.5%) for pain relief. She was extubated and taken to ICU where she was monitored overnight.
Discussion: We have described the safe use of carefully titrated epidural anesthesia and balanced general anesthesia for two different CDs in a parturient with severe AS. Our experience is supported by the literature.