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Can pregnancy be heartless?: The successful peripartum anesthetic management of a parturient with a Left Ventricular Assist Device
Abstract Number: F 61
Abstract Type: Case Report/Case Series
Mechanical cardiac replacement therapy, or the so-called “artificial heart,” is being used with increasing frequency as a bridge to transplant. It is so successful that many patients live close to normal lives outside of the hospital while supported by these devices. This is well illustrated by the patient reported here- a young woman with end-stage cardiac failure who became pregnant, and carried the pregnancy to a term vaginal delivery while being supported by a left ventricular assist device (LVAD). This is the first such case ever reported. (Other details of the case have been previously described from the cardiology perspective(1)). Our discussion illustrates the unique perioperative and peripartum issues posed by LVADs during pregnancy, particularly in the setting of persistent uncorrected RV cardiomyopathy. We report the successful anesthetic management of the labor and delivery of a parturient with bi-ventricular end stage heart failure on continuous LVAD support.
A 26 year old G7P2 female with non-ischemic dilated cardiomyopathy required the placement of a HeartMate II LVAD as a bridge to transplant. After device implantation, she became pregnant, and was advised about the risks to her and the fetus of continuing the pregnancy. However, she declined termination. She instead underwent cervical cerclage placement at 14 weeks gestation under general anesthesia in the setting of coagulopathy from acquired von Willebrand’s syndrome (AVWS)(2). At 34 5/7 weeks of gestation, she developed intermittent abdominal pain that was presumed to be early labor. She was brought to the OR and received fresh frozen plasma to reverse AVWS. A radial arterial line, PA catheter, and a slowly loaded epidural were placed, the latter in order to mitigate sympathetically mediated hypertension, tachycardia, and possible cardiac decompensation associated with labor pain. After more than 24 hours of a trial of induction and labor augmentation, RV filling pressures precipitously rose and her existing mitral regurgitation worsened, but she responded well to intravenous infusions of milrinone and nitroglycerin. She underwent an assisted-vaginal delivery and a healthy male infant was delivered without complications.
Cardiac output was well-mainatined by the LVAD throughout pregnancy and labor. However, since only the LV was replaced mechanically, some RV decompensation was observed and treated. Further complicating this case was the potential for excessive bleeding. This may be partially attributable to a phenomenon known as acquired von Willebrand’s syndrome (AVWS), characterized by a loss of high molecular weight multimers of von Willebrand’s factor. It has been suggested that blood is exposed to artificial shear stress from VAD cannulas, tubes, and rotors, and that this is the most likely contributing factor to the development of AVWS(2)
1. Journal of Heart and Lung Transplantation 2011; 30:1065-7
2. Journal of the American College of Cardiology 2010; 56:1207-13