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Anesthesia for cesarean delivery in a parturient with repaired tetralogy of Fallot variant
Abstract Number: F1C-5
Abstract Type: Case Report/Case Series
Tetralogy of Fallot (TOF) is the most common cyanotic heart disease encountered in patients surviving into adulthood in the United States. Obstetric, cardiac and anesthetic concerns in parturients with TOF include development of congestive heart failure, intrapartum arrhythmia and neonatal death. Few reports are available in the literature in regards anesthetic management for these patients(1-3).
We report a case of a 32 year-old female G1P0 who presented at 32 5/7 weeks of gestation for elective cesarean section for intrauterine growth restriction (IUGR). Her past medical history was remarkable for anxiety and complex congenital heart disease with a TOF variant (pulmonary valve atresia with ventricular septal defect) repaired during childhood, followed by multiple pulmonary arteries re-stenting and dilation procedures, pulmonary valve re-replacement and tricuspid valve repair. She was in good functional status before pregnancy which, however, was complicated by exertional chest pain, peripheral edema, lightheadedness, and palpitations, worsening during her third trimester. She was consequently treated with beta blockades and diuretics. Echocardiography at week 31 of pregnancy indicated a significant increase in the right ventricular systolic pressure (RVSP) at 72 mm Hg, moderate right ventricular enlargement and preserved left ventricular function. Numerous episodes of ventricular ectopy were evident on Holter monitoring. Given concerns for IUGR associated with critically abnormal umbilical artery Doppler studies, obstetric, cardiology, and anesthesia teams, collectively decided to pursue cesarean delivery in a cardiac operating room. Per patient request, the procedure was performed under general anesthesia with endotracheal intubation. In addition to standard ASA monitors, a radial arterial line was placed after induction. The patient remained hemodynamically stable throughout the entire procedure without evidence of cardiac arrhythmias. At the end of surgery she was successfully extubated and she was transferred to the cardiac Intensive Care Unit (ICU) for postoperative monitoring. Her ICU course was unremarkable and she was transferred to the floor 24h after surgery. She was discharged from the hospital on postoperative day 3. On follow-up echo 3 months postpartum, her RVSP remained elevated at 78 mmHg; however, her symptoms completely resolved and she returned to her baseline functional status.
Hemodynamic changes during pregnancy are concerning in TOF patients. Most patients tolerate pregnancy and delivery quite well despite the elevated risk of developing right ventricle failure, endocarditis, congestive heart failure, and arrhythmias. A multi-disciplinary team composed of obstetricians, anesthesiologists, and cardiologists can help guide management.
1) Anesth Analg 2011;113:307–17)
2) J Am Coll Cardiol 2004;44:174–80
3) Int J Obstet Anesth. 2010 Jul;19(3):298-305