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Anesthetic Management of a Parturient with New York Heart Association (NYHA) Class IV Heart Failure and Drug-Induced 5% Ejection Fraction
Abstract Number: F1C-10
Abstract Type: Case Report/Case Series
The parturient with severely depressed cardiac function presents a unique challenge to the multidisciplinary team involved in the patient's care. Few studies have been published regarding the anesthetic management of parturients with pre-existing dilated cardiomyopathy.1, 2
A 37-year-old G2P1 female presented as a transfer to the ICU from an outside facility at 27 weeks gestation in cardiogenic shock. The patient's history was significant for an uncomplicated vaginal delivery 12 years prior, previous cocaine and LSD use, and current marijuana and methamphetamine use. A transthoracic echocardiogram revealed a 5% ejection fraction, grade III diastolic dysfunction, and severe mitral and tricuspid regurgitation. Given her 6.6 cm left ventricular end diastolic diameter and onset of symptoms before pregnancy, the acute heart failure was determined to be a result of drug-induced non-ischemic cardiomyopathy. A pulmonary artery catheter was placed and revealed cardiac output of 1.9 L/min, systemic vascular resistance of 3100, and a pulmonary artery diastolic pressure of 30 mmHg. With medical management, she was hemodynamically stable and discharged after six days to attend to a family emergency. Upon planned readmission two days later, a fetal ultrasound was performed and demonstrated absent end diastolic flow. The decision was made to proceed with Cesarean delivery. A pulmonary artery catheter and arterial line were placed. An epidural was inserted at L3-L4. Defibrillator pads were applied to the patient and dobutamine was infused at 2 mcg/kg/min with milrinone at 0.125 mcg/kg/min. The epidural was slowly dosed with 100 mcg of fentanyl and 2% lidocaine in four 50 mg increments over a period of 15 minutes. The cardiothoracic surgery team placed extracorporeal membrane oxygenation (ECMO) wires in the left femoral vein and right femoral artery in preparation for possible emergent ECMO cannulation. After delivery of the infant, 3 mg of epidural morphine was administered.
The incidence of parturients with such severe pre-existing dilated cardiomyopathy is low, likely due to the fact that women in such a condition would likely be too ill for conception or would have progressed to death.3, 4 However, there has been a recent increase in drug-induced dilated cardiomyopathy in pregnancy. In order to better establish treatment guidelines and to improve maternal and fetal outcomes, further studies are required to investigate parturients with pre-existing cardiomyopathy.
1 Elkayam U, et al. High-Risk Cardiac Disease in Pregnancy: Part II. J Am Coll Cardiol. 2016 Jul 1.
2. Avila WS, et al. Pregnancy in Patients with Heart Disease: Experience with 1,000 Cases. Clin Cardiol. 2003 Mar;26(3):135-42.
3 Pernstein PS, et al. Cardiomyopathy in Pregnancy: A Retrospective Study. Am J Perinatol. 2001 May;18(3):163-8.
4 Grewal, J et al. Pregnancy Outcomes in Women with Dilated Cardiomyopathy. J Am Coll Cardiol. 2009 Dec 29;55(1):45-52.