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Anesthetic management of a parturient with single ventricle physiology for cesarean delivery
Abstract Number: F-67
Abstract Type: Case Report/Case Series
A 33 year old G3P1011 at 38 weeks gestation presented with labor pain. Her past medical history was significant for tricuspid atresia with Fontan correction at age 4. She denied cardiac symptoms during pregnancy and had normal function of her single systemic left ventricle on an echocardiogram. Her obstetric history was significant for one prior uncomplicated vaginal delivery with epidural analgesia.
An arterial line was placed and intravenous fluids bolused immediately prior to and during labor epidural placement to maintain adequate preload. She received a combined spinal epidural (CSE) for labor analgesia with minimal maternal changes in hemodynamics or fetal heart rate. However, several hours later, she was called for an urgent cesarean delivery (CD) for a nonreassuring fetal heart tracing. The labor epidural catheter was utilized for anesthesia and the CD proceeded uneventfully. She recovered in the cardiac care unit postpartum.
Discussion: The prognosis for patients with congenital cardiac disease has greatly improved, and patients are now surviving to childbearing age and beyond. Tricuspid atresia is a condition where the tricuspid valve is not developed, resulting in a hypoplastic right ventricle. An interatrial communication is needed to sustain single ventricle physiology. The left ventricle provides pulmonary and systemic blood flow in parallel circuits. The ratio of flow is dependent on the ratio of pulmonary vascular resistance to systemic vascular resistance (PVR:SVR). Fontan correction occurs in early childhood to allow for passive blood flow to the lungs from the venous system while the left ventricle supplies systemic flow.
The primary goal during anesthetic care is a high preload and low afterload state with a beneficial PVR:SVR ratio. Stable cardiac output and sinus rhythm must be maintained. Ventilation goals include low peak pressures, short inspiratory times, and a low to normal PaCO2 to maintain a low PVR and high preload. Spontaneous ventilation should be utilized when possible. Neuraxial techniques are generally limited to low-dose CSE or epidural in an effort to avoid a sudden sympathectomy, which could cause shunt reversal and hypoxic systemic flow. For general anesthesia, stable hemodynamics is essential, and ketamine or etomidate can be used for induction.
For our parturient, epidural placement provided labor analgesia and provided neuraxial anesthesia for cesarean delivery, thus allowing for spontaneous ventilation during surgery. Generous preload, incremental epidural dosing, and continuous blood pressure monitoring allowed for hemodynamic stability and avoidance of shunt reversal.
Jooste et al. J Clin Anesth. 2013;25:417-23.
Lake et al. Pediatric Cardiac Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2005.