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Management of a parturient with congenital heart disease and left transposition of the great arteries with symptomatic SVT presenting for ablation
Abstract Number: SAT-68
Abstract Type: Case Report/Case Series
Background: Congenital cardiac disease in parturients presents unique challenges to the anesthesiologist. Specifically, patients with congenitally corrected transposition of the great arteries may have altered physiology, hemodynamically unstable arrhythmias and are more prone to have severe cardiopulmonary compromise during pregnancy. Solid understanding of the interactions between pregnancy and altered cardiac physiology helps the anesthesiologist anticipate and manage perioperative complications during non-obstetric procedures.
Case: We present a 24 year-old obese parturient (BMI 43) G2P1 at 17WGA with PMH of dextrocardia with congenitally corrected left transposition of the great arteries presenting with progressive dyspnea, palpitations and SVT on ECG. She was admitted and medically treated for refractory SVT with follow up recommendations for catheter ablation after delivery. Due to persistence of SVT and potential maternal and fetal compromise, a multidisciplinary discussion was held to discuss management. The plan included non-fluoroscopic SVT ablation performed via catheterization with the aid of a 3D electroanatomical mapping system to limit fetal radiation exposure. FHR monitoring was performed pre and post-operatively. Monitored anesthesia care was performed including patient positioning in LUD, O2 by nasal cannula, a pre-induction arterial line, IV midazolam for anxiolysis, and remifentanil infusion of 0.05 mcg/kg/min. SVT was induced during the procedure and the left accessory pathway was successfully ablated.
On the following morning, she re-entered SVT and was brought back for repeat ablation with the same MAC anesthesia regimen. Patient tolerated both procedures well and had no repeat occurrences. Her antiarrhythmic medications were discontinued and she was discharged home.
Discussion: Potential problems encountered with congenitally corrected transposition of the great arteries in pregnancy include dysfunction of a systemic right ventricle, atrial arrhythmias, atrio-ventricular block, and heart failure, as well as increased rate of fetal loss. Our patient presented with symptomatic SVT with signs of decompensation that was refractory to medical therapy. Her symptoms most likely would continue to worsen due to the increased cardiac output with increasing gestational age which necessitated a more definitive treatment modality such as non-fluoroscopic radiofrequency catheter ablation. Intraoperative considerations included maintaining patient hemodynamic status with close invasive monitoring. To optimize maternal as well as fetal safety, a multidisciplinary approach to management was undertaken by utilizing non-fluoroscopic technique and administering pharmacological agents that exhibit minimal fetal effect while providing anxiolysis and analgesia to the parturient.
1) Arendt K et al. A&A. 2008 Dec;107(6):1973-1977
2) Dob DP et al. IJOA. 2010 Jul;19(3):298-305