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Labor and assisted-vaginal delivery in the setting of left ventricular noncompaction cardiomyopathy
Abstract Number: S-58
Abstract Type: Case Report/Case Series
Left ventricular noncompaction cardiomyopathy (LVNC) is a relatively rare primary genetic cardiomyopathy believed to be caused by the arrest of the normal embryogenesis of the endocardium and myocardium. LVNC shows variability in its genetic pattern, pathophysiology and clinical presentations, ranging from asymptomatic patients to those who develop ventricular arrhythmias, thromboembolism, heart failure and sudden cardiac death. Pregnancy outcomes in LVNC are currently not well described. We present a rare case of LVNC in a preterm patient induced for preeclampsia, and the first reported case of an epidural anesthetic for labor and instrumented-vaginal delivery.
A 29 year-old (G3P1011) at 36+4 weeks gestation with a past medical history of congenital LVNC on Cavedilol presented with severe headache, high blood pressures, and new onset facial swelling. Pre-labor transthoracic echocardiography was significant for moderate left atrial and ventricular enlargement, marked apical trabeculation, global hypokinesis and an ejection fraction of 30-35%. Fluid restriction at 50ml/hr and magnesium sulfate was started on induction of labor for preeclampsia. An epidural was placed at L4-5 interspace with a bolus of 3ml of 1.5% lidocaine and a subsequent infusion of 0.1% bupivacaine and 2 mcg/ml of fentanyl at 10 ml per hour. After an uneventful labor course, during the second stage of labor, the epidural was dosed over 90 minutes with lidocaine 2% with epinephrine and fentanyl 100 mcg in small aliquots of 3 to 5 ml. On complete cervical dilation and fetal presentation at +3 station, the block resulted in a T6 dermatome level. Despite this high sensory level, there were no significant hemodynamic changes resulting in a successful, painless outlet forceps vaginal delivery. Repeat post-delivery echo was unchanged and she was discharged on post-partum day 3 without any sequelae.
LVNC or “spongy myocardium” is characterized by a compact epicardial layer and a non-compacted endocardial layer with prominent trabeculations. It is an uncommon condition with a genetic pre-disposition that can occur in isolation or in association with other cardiac anomalies. Management is directed at clinical manifestations: heart failure, arrhythmias, and systemic embolic events. With respect to the few case reports in the literature, initial presentation/prognosis varies, with parturients presenting asymptomatic to fulminant heart failure requiring transplantation. Pregnancy and childbirth can usually be managed successfully in patients with LVNC, as in other cardiac conditions, if the diagnosis is made early and appropriate interventions are performed as occurred in this case, depicting the first reported case with an epidural anesthetic for labor and vaginal delivery.
Ashford, Eric J, et al. (2014). J of Clin Anes 26: 490-494.
Lea, Brian et al. (2012) International Journal of Cardiology 154: e65-e66.