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Management of a parturient with congenital heart disease and left transposition of the great arteries with congestive heart failure presenting for cesarean delivery
Abstract Number: SU-19
Abstract Type: Case Report/Case Series
Background: The management of parturients with complex congenital cardiac disease is a challenging task for the anesthesiologist. Their complex pathophysiology can lead to hemodynamic instability, arrhythmias and even cardiac arrest under anesthesia. Anesthesiologists must understand the physiology of the individual’s pathology and use monitoring and clinical signs to direct care.
Case: We present a 22 year old obese (BMI 41) G4P2012 @ 35+3 with a PMH of acyanotic congenitally corrected left transposition of the great arteries and congenital complete heart block s/p pacemaker placement at the age of 12 presenting to our hospital with worsening dyspnea, intermittent chest pain and a decline in functional status. A TTE showed an EF 20-25%. The patient was admitted to the CCU for acute fluid overload and was treated with furosemide and digoxin. A multidisciplinary discussion was held to discuss optimal timing and approach to delivery.
Once the patient’s fluid status was optimized, the decision was made to deliver the fetus via repeat cesarean delivery due to the likelihood of worsening cardiac status. Preoperatively, the pacemaker rate was adjusted to 100 bpm from 80 bpm to assist with expected increases in cardiac output from delivery. A central line and a pre-induction arterial line were placed. The cesarean delivery was successfully performed under graded segmental epidural catheter anesthesia. Throughout the procedure an Edward Life Science Vigileo was used to monitor cardiac output, stroke volume and stroke volume variation. Following delivery, the patient complained of chest pain - her BP dropped to 81/47. Concurrently, her cardiac index increased from 3.4L/min/m2 to 4.8L/min/m2 and then rapidly dropped to 2.7L/min/m2 with a simultaneous fall in SVV from 10% to 5%. Furosemide and additional epidural lidocaine were administered and a dobutamine infusion was added for inotropic support. The chest pain resolved and cardiac parameters returned to baseline. The subsequent surgical course was uneventful.
Discussion: Females with complex congenital heart disease undergo significant cardiovascular challenges during pregnancy and delivery. The increase in cardiac output and intravascular volume from autotransfusion following delivery may trigger cardiac failure. These same patients, however, may become hypovolemic secondary to acute blood loss and those who are pacemaker dependent may be unable to compensate. Discerning which physiological change predominates may prove to be difficult. Our intraoperative use of a non-invasive CI and SVV monitor allowed us to discern this patient was hypervolemic with acute heart failure. This information prompted us to give dobutamine for inotropic support, to bolus the epidural catheter to decrease peripheral vascular resistance and increase vascular capacitance, and to administer furosemide for diuresis.