Anesthetic Management of a Parturient with Cardiac Stents in a Transplanted Heart Following Peripartum Cardiomyopathy
Abstract Number: T-47
Abstract Type: Case Report/Case Series
INTRODUCTION: Neither peripartum cardiomyopathy, nor coronary artery disease are common in pregnancy. This combination in the parturient is even more rare, presenting unique challenges to the care team. The physiologic changes of pregnancy, combined with stresses of labor and delivery, increase cardiovascular requirements significantly. This impacts the balance between myocardial oxygen supply and demand, potentially worsening ischemia.(1) Coronary stenting improves myocardial blood flow, but requires ongoing antiplatelet therapy for thrombus prevention. This drug therapy limits the use of neuraxial blockade as part of the anesthetic plan secondary to the risk of epidural hematoma.(1)
CASE: A 26 year old G4P1021 parturient presented for anesthetic evaluation. Her medical history was significant for peripartum cardiomyopathy requiring cardiac transplantation. Following transplantation she developed three vessel coronary artery disease during medication noncompliance requiring placement of a drug eluting coronary stent. Additional comorbidities included anemia, gastric reflux, and sickle cell trait. Medications included clopidogrel, aspirin, tacrolimus, and vitamin supplements. Echocardiography demonstrated an EF of 60% with moderate left atrial enlargement, pulmonary HTN, and mild tricuspid regurgitation. Physical exam revealed a systolic ejection murmur.
Anesthesiology, obstetrics, and cardiology developed a multidisciplinary approach to the management of her intrapartum care. Clopidogrel was discontinued 15 days prior to a planned IOL at 37 1/7 weeks. An early labor epidural was placed in an effort to mediate stress catecholamines and decrease the subsequent demands on the heart. Invasive monitoring was intended (arterial line, PA catheter), at the first sign of decompensating hemodynamics. Fortunately, she had an uncomplicated vaginal delivery without the need for invasive monitors.
DISCUSSION: Peripartum cardiomyopathy is a rare and poorly understood condition carrying a significant risk to the mother and fetus.(2,3) Although the literature advises against future pregnancies in patients with continued left ventricular dysfunction, recommendations are less clear if cardiac function returns to baseline.(2,4) Cases of successful pregnancy following cardiac transplant are well documented, but few reports exist of patients whose transplant was the result of peripartum cardiomyopathy.(2,5) Our case was further complicated by coronary artery disease and stent placement of a transplanted heart. Expected complications following cardiac transplantation arise from the use of immunosuppressive agents and lack of functional autonomic innervation.(2) A multidisciplinary care plan is imperative to maximize patient outcomes.
1. Int J Obstet Anesth 2005;14:167-71.
2. J Obstet Gynaecol Can 2007;29:575-9.
3. Br J Anaesth 2004;93:428-39.
4. Eur Heart J. 2002;23:753-756.
5. Eur Heart J 1992;13:1589-91.