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Obstetric anesthetic management of a patient with surgically repaired dextro-Transposition of Great Arteries
Abstract Number: T-72
Abstract Type: Case Report/Case Series
Case: A 19 year-old female, G1P0, BMI 29.3, with a history of surgically corrected situs solitus, d-ventricular loop dextro-Transposition of Great Arteries (d-TGA) presented for anesthetic management for vaginal delivery. The patient underwent an arterial switch, repair of ASD and VSD at age 2 months. At presentation she was WHO Class III maternal cardiovascular risk and had NYHA Class II symptoms. History was also significant for persistent left SVC, asthma, left bronchial compression by the pulmonary artery and repaired thoracolumbar scoliosis with Harrington rods. Pre-labor transthoracic echocardiogram(TTE) showed preserved LVEF (>60%), 3+ AR, 3+ TR and mild PAH. Initially, large bore IV access was obtained, and an arterial line was placed. Ultrasound of her thoracic and lumbar spine was performed to assess her hardware, and confirm normal anatomy at the planned level of epidural(Fig 1-1). An epidural was placed at L3/4 early in her labor to provide time for slow up-titration of analgesia and avoid dramatic hemodynamic shifts. One hour post epidural, the epidural concentration was up-titrated to obtain dense sensory blockade in the event that she required forceps or vacuum assisted delivery. Concentration was increased from 0.04% bupivicaine/1.7mcg/ml fentanyl(BF) to 0.0625%, 0.08%, 0.125% and 0.1875%/1.7mcg/ml BF at one hour intervals. All infusions were run at 15ml/hr. Prior to delivery, a TTE and pulmonary ultrasound was performed to assess the patient’s cardiac and volume status. TTE was stable, with normal systolic function, 3+AR and no pericardial effusion.(Fig 1-2). The patient had intermittent discomfort which was relieved with small bolus dosing of 0.25% bupivicaine. After briefly pushing, without cardiovascular symptoms, the patient delivered a healthy male infant.
Discussion: TGA has an approximate incidence of 5/10,000 live births in the US and after surgical repair, neo-aortic valve regurgitation, dilation of the aortic root, pulmonary artery stenosis and coronary stenosis have been described. Anesthetic management of these patients hinges on the maintenance of their normal baseline physiology, and requires individualized care. This case raises the possibility that valsalva and expulsive efforts may be safe in carefully selected patients with a history of congenital heart disease.
Cannesson M, Earing MG, Collange V, Kersten JR. Anesthesia for Noncardiac Surgery in Adults with Congenital Heart Disease. Anesthesiology. 2009;111(2):432-440