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Non-Invasive Cardiac Monitoring for Labor and Delivery in A Parturient with Ebstein’s Anomaly Status-Post Redo Tricuspid Valve Replacements
Abstract Number: T-42
Abstract Type: Case Report/Case Series
A 32-year-old woman with an atrial septal defect (ASD) and Ebstein’s anomaly status-post patch closure of ASD plus tricuspid valve replacement (TVR) at age 7 and redo TVR in 2003, and Wolf-Parkinson-White status-post ablation presented to the labor and delivery unit for a scheduled induction of labor. Patient’s history was also significant for right heart failure in 2003. Since then, she had been asymptomatic and had worked on international assignments before returning to the United States during her pregnancy. On admission, her exam was significant for mild jugular venous distention and trace lower extremity edema. Recent echocardiography demonstrated a left ventricular (LV) of normal size and an ejection fraction of 50-55%. The right ventricle (RV) was enlarged with severely reduced systolic function. The interventricular septum bowed markedly toward the LV in both systole and diastole, consistent with RV overload. There was trace to mild mitral and tricuspid regurgitation and the tricuspid valve mean gradient was 7 mmHg, which is unchanged from her post-surgical echo. The patient was evaluated by the adult congenital heart service and recommendations were to aim for an even fluid balance. In order to minimize labor stress and upon patient’s consent, epidural analgesia was placed at early stage of labor. The anesthesia team elected to apply a non-invasive cardiac output monitoring (NICOM®) to guide the patient’s fluid management. Goal of stroke volume variation (SVV) was kept around the patient’s baseline of 14% with stroke volume index (SVI) at around 34. The patient delivered a healthy boy 13 hours after epidural placement with no evidence of fluid overload. Postpartum, patient underwent an uneventful dilation and evacuation for retained placenta.
DISCUSSION: Pregnancy and labor are associated with significant hemodynamic changes, and traditionally, heart rate and blood pressure have been used as surrogate measures for cardiac output and volume status. For a patient with prior cardiac history, invasive monitoring techniques have been used to assess volume status and cardiac output. However, pulmonary artery catheter usually cannot be justified in parturients given their associated complications. SVV, SVI, and pulse pressure variation are newer parameters being used to determine fluid responsiveness. These values can be obtained via less invasive (e.g., arterial line contour tracing) or non-invasive (e.g., bioreactance® or transthoracic bioimpedance), however have been studied primarily in mechanically-ventilated patients. Non-invasive cardiac output monitoring may be a valid tool in the obstetric population and certainly has increasing relevance in patient monitoring and tailoring appropriate fluid management, particularly in patients with prior cardiac history.
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