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///2015 Abstract Details
2015 Abstract Details2019-08-02T16:54:43-05:00

Neuraxial Anesthesia for Cesarean Delivery in a Parturient with Critical Aortic Stenosis: A Case Report

Abstract Number: F-45
Abstract Type: Case Report/Case Series

Ku-mie Kim M.D., Ph.D.1 ; Elizabeth Tentler M.D.2

Introduction: Neuraxial anesthesia (NA) in patients with severe aortic stenosis (AS) has been considered contraindicated since fixed CO may not compensate the reduced preload and SVR to maintain hemodynamic stability. We present a case of sequential combined spinal-epidural (CSE) anesthesia for cesarean delivery (CD) in a parturient with critical AS. Case: A 25 y/o, G2P0, was seen for OB anesthesia consult at 25 wks in gestation for h/o coarctation of aorta (CoA) and severe bicuspid AS. She had repair of CoA and aortic valvuloplasty at age 2 mo. and repeat valvuloplasty at age 4 and 18. She was asymptomatic until the current pregnancy. Previous pregnancy had been terminated due to her cardiac condition. Echo showed AVA 0.7cm2, peak pressure gradient (PG) of 123 mmHg, LVEF 81% and no residual CoA. IOL at 39 wks for assisted vaginal delivery was planned. However, she started deteriorating at 38 wks with SOB and orthopnea. Echo showed AVA 0.4cm2, PG up to 150 mmHg and reduced EF (63%). She was taken for CD at 38 3/7 wks with thorough preparation including CP bypass stand-by. A-line was placed preoperatively. Preop vitals were 120/80mmHg, SR at 78/min, SpO2 100%. After 700ml of IVF, sequential CSE was administered at L3-4 with initial hyperbaric spinal bupivacaine 6mg and fentanyl 15mcg. After positioning to supine with left uterine displacement, the initial level was T11. During next 35 min, after negative test dose, total 12ml of epidural lidocaine 2% was administered incrementally to obtain T4 level. She remained stable and did not require any vasopressor. Incision was made 43 min after initial spinal injection. After delivery of newborn, slow infusion of oxytocin (40 U/L) was started. PF-free morphine 3mg was given epidurally. She remained hemodynamically stable on SR throughout the case. Total IVF was 1500ml and EBL 700ml, respectively. Postop course was uneventful with adequate analgesia, improved clinical symptoms and reduced PG to 83mmHg on echo. She was discharged home on POD#4 and underwent uneventful AV replacement at pp week 7. Discussion: The goal for anesthetic management in patients with severe AS should be hemodynamic stability by maintaining SR, adequate HR and preload, and avoiding rapid decrease in SVR. Although GA is believed the gold standard for CD in patients with severe AS, the best anesthetic is still a debating issue.1,2 Sequential CSE should be considered the technique of choice even in a case with critical AS, because of its excellent controllability with slow titration, consequent hemodynamic stability, solid quality, and negligible incidence of PDPH.3 In our case, early multidisciplinary involvement, perioperative hemodynamic stability with slowly titrated NA and thorough preparation for emergent cardiac intervention have contributed to the favorable outcome. References: 1. Brighouse D. Anaesthesia 1998;53:107 2. Whitfield A, Holdcroft A. Anaesthesia 1998;53:109 3. Rawal N, et al. Reg Anesth 1997;22:406.

SOAP 2015