///2017 Abstract Details
2017 Abstract Details2018-05-01T18:00:49+00:00

Non-invasive cardiac output monitoring for cesarean delivery in patient with Eisenmenger's physiology

Abstract Number: F-58
Abstract Type: Case Report/Case Series

Caroline Martinello MD1 ; Erin G Sreshta MD2; Medeiros A Felipe MD3; Lozada M James MD4; MIchelle Simon MD5; Vadhera B Rakesh MD, FRCA, FFARCS6

Eisenmenger syndrome has an incidence of 3% among parturients with congenital heart defects. Peripartum period is associated with high morbidity and mortality and proper anesthetic management is critical for positive outcome. Case report:24 yo G2P0 at 35 weeks. History of CHF and Eisenmenger physiology due to persistent ductus arteriosus on medical treatment (digoxin, furosemide, metoprolol). Admitted for dyspnea with improvement after diuresis and starting sildenafil. Transthoracic echocardiography (TTE) showed severe pulmonary hypertension with estimated RVSP of 94mmHg, normal EF and Qp/Qs 0.94. After a multidisciplinary meeting involving MFM, anesthesiology and cardiology, plan was for cesarean delivery (CD) at 37w gestation for breech presentation. Monitoring included invasive blood pressure, CVP, non-invasive cardiac output (CO) monitor (ICON™) and pre and post-ductal SpO2. Epidural catheter was placed and 400mg lidocaine 2% with NaHCO3 2mEq and epinephrine 50mcg was dosed over 20 min. Five min after delivery patient complained of chest pain. A drop in systemic vascular resistace (SVR) was noted [figure 1] followed by a decrease in MAP to 65 from baseline of 90mmHg. SpO2 was maintained. Milrinone and vasopressin infusions started with clinical improvement. Patient was transferred to ICU where an epidural infusion of bupivacaine 0.125% was continued for 20h. Vasopressin was discontinued upon arrival and milrinone was discontinued 18h after delivery. Repeat TTE was unchanged except for Qp/Qs of 1.67. Postoperative course was uneventful and she was discharged after 9 days. Eisenmenger syndrome parturients are particularly vulnerable to hemodynamic changes induced by anesthesia, surgery and postpartum period. Care for these patients is complex and requires a multidisciplinary collaboration. CD should be reserved to obstetric indications. Perioperative goals are to maintain SVR, sinus rhythm and myocardial contractility while avoiding increases in pulmonary vascular resistance. Invasive monitoring is often necessary to help achieve these goals however carries risk of complications. ICON™ is a non-invasive CO monitor which uses thoracic bioreactance analysis to estimate hemodynamic indices. It has shown good agreement with TTE and it is especially valuable to display trends in hemodynamics. It may also be continued on postoperative period helping optimize hemodynamic management.[1]Braz J Cardiovasc Surg. 2016;31:325 [2] Ultrasound Obstet Gynecol. 2017;49:32

SOAP 2017