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Atrial Thrombectomy Requiring Heparinization and Cardiopulmonary Bypass Post-Partum Day Two
Abstract Number: T-12
Abstract Type: Case Report/Case Series
Background: Cardiopulmonary bypass (CPB) during pregnancy and postpartum (PP) has been described in the literature.1 It is recommended that timing of the cardiac operation be in the 3rd trimester and that delivery of the fetus should occur prior to CPB.1 CPB necessitates an extreme state of anticoagulation, and therefore concerns exist regarding its safety and risk of hemorrhage in the immediate PP period; however, no specific recommendations exist. We present a case of a patient in her 3rd trimester with an atrial thrombus prompting fetal delivery, and thrombectomy with CPB PP day 2.
Case: A 33 year old G5P2022 patient at 30 5/7 weeks gestation presented with a history of Crohn’s disease, and a previous peripherally inserted central catheter (PICC)-associated deep vein thrombosis. Her current pregnancy was complicated by malnutrition and hyperemesis requiring total intravenous nutrition (TPN) through a central venous catheter (CVC).
Throughout the pregnancy, the patient had multiple CVCs complicated by thrombosis and infection. She was admitted to the medical intensive care unit (MICU) at 30 2/7 weeks gestation for treatment of a suspected CVC- associated infection and sepsis.
The patient was transferred from the MICU to Labor and Delivery (L&D) for tocolysis due to preterm labor. She remained on antibiotics for her infected tunneled CVC (tip in the superior vena cava) so that TPN could be continued. In L&D, an acute decrease in hemoglobin from 8.2 to 5.8 g/dL prompted a transthoracic echocardiogram to evaluate whether there was expansion of a previously imaged pericardial effusion since the patient was not demonstrating any active signs of bleeding.
A multilobulated right atrial thrombus was visualized adherent to the CVC. A multidisciplinary team convened and implemented a plan that called for delivery of the fetus at 31 weeks gestation under general anesthesia in the cardiac operating room with cardiothoracic surgery and CPB on standby. Following the uneventful delivery, a heparin drip was started 10 hours PP, and a successful thrombectomy with heparinization and CPB was performed PP day 2.
Discussion: CVCs have been associated with a complication rate of 66.4% (infection, thromboembolism).2 Turbulent flow at the catheter tip, and endothelial damage contribute to CVC thrombus formation. Isolated case reports exist describing CPB as early as 2 hours PP without hemorrhagic complications from the hysterotomy site. The continuation of oxytocin and the addition of aprotinin have been successfully used to prevent significant bleeding when cardiac surgery with CPB and heparinization is necessary immediately PP.3
Parry AJ. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 1996; 61:1865-9
Holmgren C. Hyperemesis in pregnancy: an evaluation of treatment strategies with maternal and neonatal outcomes. Amer J Obstet Gynecol 2008; 198:56.e1-4
Lamarra M. Cardiopulmonary bypass in the early puerperium. Ann Thorac Surg 1992; 54:361-3