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Management of Parturient with Subaortic Stenosis
Abstract Number: SU-73
Abstract Type: Case Report/Case Series
In the past, concerns about the hemodynamic fluctuations of neuraxial anesthesia curtailed its use in patients with aortic stenosis physiology (AS). Presently, careful titration of epidural catheters are successfully utilized in the labor management of patients with AS. We discuss the case of a patient with LVOT obstruction presenting for a cesarean delivery due to a deteriorating category II tracing remote from delivery.
18. y.o. primigravida at 37weeks referred from the Congenital Heart Disease Program due to the presence of a congenital subaortic membrane. Her chronic SOB had been erroneously attributed to asthmatic exacerbations during the past years. Pt denied syncopal episodes or history of chest pain. Patient had been poorly compliant with follow up Cardiology Clinic visits and, it was unclear if surgical repair was offered in the past. Echocardiogram revealed a mean gradient of 110 mmHg across stenotic subvalvular area, normal LV function, mild atrial dilatation and moderate pulmonary hypertension. A pre-procedural arterial line was placed for continuous BP monitoring. An epidural catheter was placed uneventfully at the L3-L4 interspace with a 17G Touhey, 11 cm from the skin. After negative aspiration, the epidural catheter was tested with 3 ml of 0.25% Bupivacaine and 100 mcg of Fentanyl to avoid possible intravascular injection of epinephrine containing solutions. The epidural catheter was incrementally loaded with 15ml of 2% Lidocaine. Hemodynamic fluctuations were attenuated with a phenylephrine infusion targeted to maintain baseline BP, prevent hypotension and avoid tachycardia (25-100mcg/min). Obstetrical Anesthesia Team had discussed and was ready to proceed with a rapid sequence induction using Etomidate and Remifentanyl (2-3mcg/min), in case of neuraxial technique failure.1 CT surgery service was alerted for the possible need of emergent intervention. A viable male infant with Apgars of 9/9 was delivered with no complications. Post operatively patient was transferred to the CCU for recovery.
Controversies exist regarding the best technique, general vs. neuraxial anesthesia, when managing patients with AS physiology. Our and other case reports have demonstrated that it is possible to manage these patients with neuraxial anesthesia and invasive monitoring, if the block is achieved slowly to the desired level to prevent rapid decreases in the SVR2. Interdisciplinary peripartum management is essential as AS continues to carry a high risk of maternal morbidity and mortality.
1. Orme R, et al. IJOA 13: 183-7, 2004.
2. Ioscovich A, et al. IJOA 18: 379-86, 2009.