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Use of a non invasive cardiac output monitor (NICOM) for epidural anesthesia for caesarean delivery in a patient with corrected aortic coarctation of aorta and aortic stenosis
Abstract Number: S-53
Abstract Type: Case Report/Case Series
Coarctation of the aorta (COA) is the 6th most common congenital heart lesion. Most cases of COA are sporadic with a definitive genetic component, leading to a 5 fold increased risk of bicuspid aortic valve in first degree relatives of children with left heart obstructive lesions, including COA, aortic stenosis (AS) and hypoplastic left heart syndrome. Long-term aortic complications after repair are common and include re-coarctation and aortic aneurysm formation (1). We report a patient with COA and AS presenting for a C-section that was performed under epidural anesthesia using Non-invasive cardiac output monitor (NICOM).
Case: 29 year old G4P2, presented for elective C-section. Her previous medical history included a prior caesarean and status post repair of COA. Her echo revealed bicuspid aortic valve with an area of 1.2 cm2 aortic stenosis, mild concentric left ventricular hypertrophy with EF> 65%. Regional epidural anesthesia was used for the C-section with incremental dosing of 2% lidocaine with fentanyl. NICOM was used to non-invasively monitor hemodynamic parameters such as cardiac output (CO), cardiac index (CI) and stroke volume (SV) as well as MAP, SBP, SBP, HR. Using NICOM and incremental dosing of IV phenylephrine (total dose 450mcg) we were able to maintain excellent surgical anesthesia with hemodynamic stability. Patient was discharged home uneventfully post operative day 3.
Discussion: Several cases have been reported using both epidural and spinal regional anesthesia, in coarctation of aorta parturients, resulting in significant hypotension requiring invasive monitoring and resuscitation (2, 3). NICOM has allowed us to guide and maintain tight hemodynamic control under epidural anesthesia in this high risk parturient. Patients with coarctation have a BP response similar to the general population (3).
Conclusion: Using our multifaceted approach we were able to use regional anesthesia as our primary anesthesia modality to provide excellent surgical anesthesia in a safe and efficient manner with the assistance of NICOM.
1. Tanous D, Lee BN, Horlick EM; Coarctation of the aorta: evaluation and management. Current opinion in cardiology 2009(24)509-515
2. Bourgeade F, malinovsky JM; Anesthesia management for caesarean section in a parturient with uncorrected coarctation of the aorta. Ann fr anesth reanim 2010(9)642-4
3. Loscovich AM, Goldszmidt E, Fadeev AV, Grinsaru-Granovsky S, Halpern SH ; Peripartum anesthetic management of patients with aortic valve stenosis: a retrospective study and literature review. International journal of obstetric anesthesia 2009,(18)379-386