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Femoral Artery Cannulation for Maintenance of Uteroplacental Perfusion During Deep Hypothermic Circulatory Arrest
Abstract Number: S 51
Abstract Type: Case Report/Case Series
Introduction: We present a novel technique to maintain uterine perfusion in the management of a pregnant patient with Takayasu’s arteritis requiring circulatory arrest for aortic valve repair and arch reconstruction. In this case, femoral artery cannulation was performed to allow for distal perfusion of the uterus after clamping the descending thoracic aorta and initiating circulatory arrest.
Case: A 30 year old G1P0 female with Takayasu’s arteritis presented at 15 weeks gestational age with worsening shortness of breath. Workup revealed severe aortic regurgitation and an ascending aortic aneurysm of 5.1 cm extending into the transverse aortic arch. After consultation with maternal fetal medicine and cardiothoracic surgery regarding maternal and fetal risks, including the possibility of an elective termination, the patient decided to continue her pregnancy and proceed with surgical repair. On the day of her surgery, after receiving standard GI prophylaxis, the patient was transported to the OR. A pre-induction right radial arterial catheter was placed. After rapid sequence induction and intubation, a left radial arterial catheter and a left internal jugular 9 French MAC introducer were placed. Next, a right axillary arterial cannula was placed, followed by sternotomy and venous cannulation for cardiopulmonary bypass (CPB). Then right femoral artery cannulation was performed, which would allow for distal uteroplacental perfusion during DHCA (Deep Hypothermic Circulatory Arrest). CPB was initiated and the patient was cooled to 24 degrees Celsius. The mean bypass flow rate was 4.4 L/min/m and the mean perfusion pressure was 60 mm Hg. DHCA was initiated after the descending thoracic aorta was clamped. Blood flow to the uterine vessels was maintained via the cannulated right femoral artery. The mean perfusion pressure of the distal thoracic aorta was maintained at 39 mm Hg during circulatory arrest. Transverse arch replacement was performed during a total DHCA time of 26 minutes. Total CPB time was 261 minutes. After transfer to the ICU, post-surgical fetal ultrasound showed no evidence of fetal heart tones and an intraoperative intra-uterine fetal demise was diagnosed. The remainder of the patient’s postoperative course was uneventful.
Discussion: Although case reports suggest fetal mortality to be as high as 20-30% during maternal surgery requiring CPB, data is limited on fetal survival after DHCA. Although the fetus did not survive the surgery, this case introduces a novel approach which maintains uteroplacental perfusion during circulatory arrest and demonstrates a potential strategy to help promote fetal survival during this critical surgery.
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