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Left Ventricular Non-Compaction Syndrome in a Parturient
Abstract Number: F-39
Abstract Type: Case Report/Case Series
Introduction: Left ventricular non-compaction (LVNC) is a rare congenital cardiomyopathy characterized by prominent trabeculations of the left ventricle. Patients may be asymptomatic or present with symptoms of congestive heart failure, atrial and ventricular arrhythmias or thromboembolic disease. We describe a case of a parturient with LVNC who presents for cesarean section(C/S) in the setting of worsening cardiac function.
Case Report: The patient was a 31 year old G4P1 diagnosed with LVNC after her first pregnancy. At that time, ejection fraction (EF) was 41%, mean pulmonary artery pressure (MPAP)=40mmHg at rest. The patient remained asymptomatic. Against medical advice, the patient became pregnant again. At 30 weeks gestation she began experiencing dyspnea and orthopnea. Transthoracic echocardiogram (TTE) revealed EF of 38%, decreased right ventricular function and unchanged MPAP. At 34 weeks her symptoms worsened and decision was made to perform a C/S. The patient was admitted to the cardiothoracic ICU the night before surgery, a pulmonary artery catheter was placed and TTE was performed that revealed EF =23% and severe pulmonary hypertension (PUL HTN) (MPAP =58mmHg). In the OR, standard ASA monitors and an arterial line were placed. Prior to induction dobutamine was started to maximize LV function and improve forward flow. Rapid sequence induction of anesthesia was achieved with etomidate 20 mg and succinylcholine 120mg and the anesthetic was maintained with isoflurane, Fi02 100%, and remifentanil infusion. A healthy male was delivered with Apgar score of 8 at both 1 and 5 min. Oxytocin 20units/hr was started. The patient developed systemic hypotension and increased MPAP. Vasopressin was bolused and an infusion started at 2units/hr. The uterus remained atonic and methylergonovine 0.2mcg was administered with improvement in uterine tone. The surgery was completed in 50 minutes, the trachea was extubated, and she was transported to the CTICU. The patient was weaned off all pressor agents on post-op day (POD) 1. The patient was discharged to home in stable condition on POD 4.
Discussion: Mode of delivery in patients with LVNC is determined by obstetrical indications and maternal functional status. C/S was recommended in this patient with worsening cardiac status. Anesthesia for C/S can include neuraxial or general anesthesia. General anesthesia was selected for this patient with LVNC and PUL HTN. Anesthetic goals in this patient required management of systolic heart failure and PUL HTN. Increases in PVR and systemic hypotension must be avoided. The critical time in regard to cardiac function is generally after delivery when cardiac output increases as occurred in our patient. A multidisciplinary approach is essential in caring for these patients. The C/S was performed in the cardiac OR, with capability of extracorporeal life support, and cardicardiothoracic surgeons on standby. This team dynamic contributed to a successful outcome.