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Dilated Cardiomyopathy Presenting As Heart Failure During Pregnancy
Abstract Number: S-16
Abstract Type: Case Report/Case Series
Heart failure during pregnancy is associated with significant morbidity. We present a case of heart failure progressing to refractory cardiogenic shock requiring Cesarean delivery (CD) and mechanical circulatory support.
32 year old G1P0, 29 week twin gestation with a past medical history of asthma was admitted with shortness of breath, productive cough, and chills. She was treated for pneumonia, but decompensated despite therapy. TTE showed global hypokinesis with EF <20%. She was medically managed with dobutamine, diuresis and afterload reduction, and a goal of delivery at 34 weeks was established. At 32 weeks, she developed worsening cardiogenic shock with acute kidney injury, mental status changes, and nausea. Dobutamine was increased and milrinone added with only slight improvement in symptoms. Decision was made to proceed with CD.
The patient was brought to the operating room with cardiac surgery backup in the event emergent mechanical circulatory support was required. Pulmonary artery catheter was in situ, and a left radial arterial line was placed. As the patient was severely dyspneic supine, general anesthesia was induced. TEE showed severe global hypokinesis with LVEF <10%. Low dose epinephrine infusion was added. Fluids were kept to a minimum in preparation for autotransfusion following delivery. Incremental doses of fentanyl were used for analgesia. She was admitted to the ICU postoperatively and extubated later that day. However, cardiogenic shock progressed over the next several days and intraaortic balloon pump was placed with significant improvement in symptoms. Ultimately, Heartmate II left ventricular assist device was placed. She was discharged home three weeks later. Outpatient evaluation revealed familial dilated cardiomyopathy.
Heart failure during pregnancy is most likely to present in the late second trimester, early third trimester or around the time of delivery. Physiologic stresses of pregnancy can unmask previously undiagnosed cardiac disease. Management of heart failure is complicated by limited data regarding use of proven agents during pregnancy and lactation. Diuretics, vasodilators, and neurohormonal blockade are mainstays of treatment. However, mechanical support is used in severe cases and is offered as destination therapy, bridge to transplant or bridge to recovery.
1. Heart 2014;100:231-8
2. Tex Heart Inst J 2012;39(1):8-16