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Anesthetic Management For a Parturient with Unrepaired Double Outlet Right Ventricle
Abstract Number: T-44
Abstract Type: Case Report/Case Series
INTRODUCTION: Congenital heart disease, in the setting of physiological changes of pregnancy, is associated with increased cardiovascular events, including heart failure, arrhythmias, stroke, and death (1,2). We present the management of a parturient with an unrepaired double outlet right ventricle (DORV) who underwent cesarean delivery under general anesthesia.
CASE DESCRIPTION: 27 year old G3P0110 with a history of unrepaired DORV, large secundum ASD with unrestrictive left to right shunt, severe pulmonic stenosis (peak gradient 100mmg Hg), cyanosis (baseline SpO2 80%), and hypoplastic LV presented to her adult congenital cardiologist in early pregnancy. She was noncompliant with anticoagulation despite prior CVAs with resultant neurologic deficits. Her LV was filled with organized thrombus. Her delivery plan was discussed at a monthly multidisciplinary conference which includes MFM, adult congenital cardiology, OB anesthesiology, and CV anesthesiology. She had one prior cesarean delivery following IUFD at 30 weeks, and plan was for repeat cesarean delivery under general anesthesia. Neuraxial anesthesia was contraindicated given severe pulmonary stenosis.
Delivery was indicated at 33w5d for IUGR. She was admitted for preoperative optimization by cardiology. Neurology was consulted for evaluation of baseline deficits given concern for ongoing LV thrombus embolization. Arterial line and CVC were placed preoperatively and hemodynamics were optimized.
At 34w1d the patient was taken to the cardiac OR for cesarean delivery with cardiothoracic surgery on standby for possible ECMO. Coagulation studies, fibrinogen and ROTEM were found to be within normal limits for pregnancy. General anesthesia was induced with etomidate and succinylcholine and maintained with sevoflurane. Nitrous oxide was avoided due to its potential to increase pulmonary vascular resistance. RV function was monitored and fluid resuscitation guided by TEE intraoperatively. Prior to emergence, bilateral ilioinguinal/iliohypogastric blocks were performed for postoperative analgesia. Postoperative course was uneventful and she was discharged 6 days after surgery.
CONCLUSION: This case demonstrates the successful multidisciplinary management approach used for parturients with high risk cardiovascular disease at our institution. Careful planning and collaboration were crucial to successful management of this complicated patient.
1. Heart. 2011;98:145–151
2. Circulation. 2014; 130: 273-282