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Epidural Anesthesia for Cesarean Delivery in a Parturient with Transposition of the Great Vessels
Abstract Number: T-68
Abstract Type: Case Report/Case Series
A 31 year old G1P0 parturient with history of d-transposition of the great arteries was referred to our facility at 37 weeks gestation for consultation and management of delivery. The patient had undergone a Senning (atrial switch) procedure at 6 months of age. Her most recent echocardiogram showed hypertrophied right ventricle with decreased function managed with carvedilol and furosemide. Her past medical history was also significant for steroid controlled juvenile rheumatoid (JRA) arthritis. The patient was scheduled for cesarean section due to her history of a hip replacement. Prior to entering the operating room, a central line was placed in the patient’s right internal jugular vein secondary to poor peripheral access because of her dysmorphisms. As planned, the epidural was dosed slowly after arterial line placement to achieve her hemodynamic goals in light of her decreased systemic ventricular function. Prior to surgery a milrinone infusion was started to augment the patient’s cardiac output. The patient’s heart rate did increase after delivery secondary to autotransfusion which was treated with esmolol. Because of the fear that the large increase in intravascular volume and cardiac output that occurs immediately after delivery could cause acute systemic sided heart failure, we limited intravascular fluids to one liter of lactated ringers as dictated by CVP and stroke volume variation, and furosemide 20 mg IV was administered after delivery of the baby.
In the original Senning repair, systemic venous blood is routed to the left ventricle and then to the pulmonary circulation to be oxygenated. The oxygenated blood is then returned to the right ventricle and subsequently to the systemic circulation. Thus, in patients who have undergone Senning procedure, the right ventricle is the systemic ventricle. In the obstetric population, the increase in intravascular volume and cardiac output that occurs during pregnancy and more so immediately after delivery can significantly stress this systemic ventricle. This case illustrates the necessity of communication between a multidisciplinary team in order to safely manage these patients with altered cardiopulmonary physiology.
Jonas, Richard A., and James A. DiNardo. Comprehensive Surgical Management of Congenital Heart Disease. London: Arnold, 2004. Print
Mullins, Charles E., and David C. Mayer. Congenital Heart Disease: A Diagrammatic Atlas. New York: Liss, 1988. Print