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Management of a Parturient with Severe Non-Ischemic Cardiomyopathy: A Multidisciplinary Approach
Abstract Number: SA-65
Abstract Type: Case Report/Case Series
Non-ischemic cardiomyopathy (NICM) is rarely encountered in pregnancy but may be associated with significant mortality. Characterized by either left ventricular or biventricular dilatation and impaired contractility, NICM results in progressive congestive heart failure. Peripartum anesthetic management of these patients may be challenging and is best achieved using a multidisciplinary approach. This case report illustrates successful multidisciplinary management of a parturient with severe NICM.
A 25 yo G3P0020 at 27 wk gestation presented with CHF and palpitations. Her medical history was remarkable for viral NICM (EF 20-25%), ventricular tachycardia, and placement of a dual chamber AID. She experienced multiple shocks from the AID over the years. Prior to this admission, she had an episode of atrial fibrillation w/ RVR and was placed on enoxaparin and sotalol. Despite good rate control, her cardiac function declined as she presented with significant volume overload, dyspnea, palpitations, and tachycardia. Antenatal assessment showed severe IUGR with estimated fetal weight <3%.
A multidisciplinary team comprised of maternal fetal medicine, obstetrics, cardiology, obstetric and cardiovascular anesthesiology managed the peripartum care. Despite optimal medical management, the fetus started demonstrating severe decelerations with evidence of placental abruption, leading to urgent cesarean delivery.
After emergent intraortic balloon pump placement, general endotracheal anesthesia was established uneventfully via rapid sequence induction using etomidate and succinycholine. Monitoring included radial and pulmonary artery catheterization and intraoperative TEE, which were used to guide administration of fluids and pressors (norepinephrine, dopamine, and milrinone drips). EBL was 600 cc. The neonate was delivered, transferred to NICU, and cesarean delivery proceeded uneventfully. The patient was transferred to the cardiac intensive care unit intubated with pressor support. She was weaned off pressors on postoperative day 1 and extubated successfully on postoperative day 2.
Patients with severe cardiomyopathy pose a significant anesthetic challenge. There is controversy regarding the best anesthetic technique with case reports supporting both general and regional techniques. A review of the literature shows a preference for general anesthesia as neuraxial may result in catastrophic effects secondary to the decrease in systemic vascular resistance.
The successful management of this patient warranted the collaborative efforts of a multi-disciplinary team with an advance plan in place. The goal was to prevent PVR and SVR changes to maintain enough pulmonary blood flow to oxygenate, but to prevent increases in pulmonary blood flow that would lead to pulmonary edema and congestive heart failure.
S.Nallam, et al. Int J of Sc Study 2014 October;2(7)