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Multidisciplinary Collaboration at Its Finest: Emergent Cardiopulmonary Bypass and Aortic Valve Replacement during Cesarean Delivery
Abstract Number: F4C-2
Abstract Type: Case Report/Case Series
Infective endocarditis with valvular disease during pregnancy is rare but associated with significant perinatal morbidity and mortality. We present successful multidisciplinary collaboration between obstetricians, cardiothoracic (CT) surgeons, anesthesiologists, cardiologists, neonatologists, and infectious disease specialists in the management of a parturient who required emergent cardiopulmonary bypass (CPB) and aortic valve replacement (AVR) during cesarean delivery (CD).
A 23 year-old G1 at 20 weeks’ gestation presented with bacterial endocarditis of the AV. Blood cultures were positive for MSSA. TEE showed a 1.25 x 1.2 cm AV globular mobile mass. After a two-week course of nafcillin therapy, she was discharged but required readmission ten days later due to chest pain and hemoptysis. Throughout hospitalization, several multidisciplinary meetings were held to coordinate the optimal plan of maternal-fetal care. At 27 3/7 weeks’ gestation, the patient had increased dyspnea and TEE revealed worsening aortic regurgitation and increasing ventricular size. Collaboratively, the decision was made to perform CD in the cardiac OR with the CT team on standby given that risks for fulminant maternal heart failure outweighed the risks of fetal prematurity.
In the cardiac OR, the patient was induced via rapid sequence induction with cricoid pressure using etomidate and succinylcholine. Delivery occurred three minutes after tracheal intubation. Immediately after placental delivery, oxygen saturations declined and MAPs markedly decreased from 75 to 30 mmHg. ACLS was initiated and the cardiothoracic team proceeded with emergent AVR. CPB was initiated 18 minutes after the initial hemodynamic decline with a total ACLS time of 5 min. Over the course of 3 hours, the AV was replaced and CPB was discontinued after insertion of an intra-aortic balloon pump. The patient required massive transfusion including 12 units PRBCs, 12 units FFP, 20 units cryoprecipitate, 2 pooled platelets and 7 mg factor VII. She was transferred to the cardiac ICU and extubated 2 days later.
Successful anesthetic management of CD complicated by emergent CPB and AVR requires meticulous multidisciplinary planning. This case represents the volatility that can arise from severe aortic regurgitation combined with pregnancy. It is overwhelmingly likely the patient experienced flash pulmonary edema and resultant heart failure due to autotransfusion. Furthermore, the parturient’s severe vasoplegia required extensive resuscitation inclusive of massive transfusion and vasopressor support. This case highlights the importance of multidisciplinary preparedness and Level IV maternal care in achieving optimal maternal-fetal outcomes.
Campuzano, K.,Roqué, H., Bolnick, A. et al. Arch Gynecol Obstet (2003) 268: 251. https://doi.org/10.1007/s00404-003-0485-x