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Anesthetic management of a parturient with severe aortic stenosis and triplets
Abstract Number: F-83
Abstract Type: Case Report/Case Series
Cardiovascular disease during pregnancy is one of the most common cause of non-obstetric maternal deaths. Cardiac output (CO) and blood volume increase by 40-50% during pregnancy. After delivery, CO further increases by 80% which can be detrimental for parturient with fixed valvular stenosis like mitral and aortic stenosis (AS). Cesarean delivery is usually preferred for patients with AS to avoid hemodynamic changes of labor.
We describe a case of 22 year-old gravida 3, para 2 with dichorionic/triamniotic triplets at 28 weeks who was scheduled for elective cesarean delivery. Past medical history was significant for congenital bicuspid aortic valve with severe AS. Patient had two balloon valvuloplasty in the past and scheduled to undergo Ross procedure but was found to be pregnant at time of workup. Patient was followed by her cardiologist during her pregnancy and was noted to have worsening dyspnea at 26 weeks of gestation. Transthoracic echocardiography (TTE) showed septal dyskinesia, ejection fraction of 55-60%, mean aortic valve gradient of 61 mmHg and peak gradient of 110 mmHg. Based on these findings, decision was made to perform cesarean delivery at 28 weeks. Patient was admitted and optimized by cardiologist who started her on oral digoxin with weekly TTE assessment. TTE prior to surgery showed improvement in septal dyskinesia with decrease in mean gradient of 46 mm of Hg.
Anesthetic plan was to perform an awake arterial and central line placement before induction of general anesthesia. After multiple attempts to get an access for arterial line under ultrasound guidance, procedure was aborted and general anesthesia was induced with intravenous etomidate and succinylcholine via central line in right internal jugular vein. Arterial line was placed successfully immediately after induction. Continuous TEE monitoring was performed after patient was sleep and patient remained hemodynamically stable through out the procedure with all three neonates delivered safely. Patient was extubated at the end of the procedure without any adverse cardiac event and was transferred to ICU for further post-operative care.
The Registry on Pregnancy and Cardiac Diseases (ROPAC) which is a multinational observational registry of parturient with structural heart disease emphasize that women with congenital AS, including bicuspid aortic valve, who become pregnant should be followed very closely by multidisciplinary team. ROPAC showed that patients with moderate AS had successful pregnancies with no mortality, although patients with severe AS can have some complications. Although our patient did not have any cardiac event, anesthesiologist should be ready to manage adverse events like acute heart failure, arrhythmia and ascending aortic dissection. The goal of this presentation is to focus on perioperative multi-disciplinary management of a parturient with severe AS who had triplets, which will be valuable addition to existing literature.