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Left Ventricular Assist Device to Facilitate Cesarean Delivery in a Parturient with Peripartum Cardiomyopathy
Abstract Number: S3C-4
Abstract Type: Case Report/Case Series
Introduction: Severe heart failure due to peripartum cardiomyopathy (PPCM) is a rare complication that is challenging to treat. The hemodynamic changes that accompany parturition are particularly stressful for patients with PPCM. A left ventricular assist device (LVAD) may be used to manage heart failure, but we are not aware of any reports of LVAD placement during pregnancy. We report here placement of an LVAD in preparation for a cesarean delivery in a patient with PPCM.
Case: A 30 year old primigravida with an uneventful pregnancy presented at 26 weeks gestation with shortness of breath, chest pain and worsening palpitations for two weeks. On admission the patient was hemodynamically unstable with non-sustained ventricular tachycardia and frequent premature ventricular contractions. A transthoracic echo (TTE) demonstrated an ejection fraction (EF) of 15%-20% and biventricular failure. She was diagnosed with PPCM and managed with diuretics and intravenous infusions of lidocaine, esmolol, and heparin. A multidisciplinary care team was assembled including specialists from obstetric anesthesia, maternal fetal medicine, surgical and cardiac intensive care, cardiothoracic surgery, pediatrics and nursing. A decision was reached to manage the PPCM medically and allow the fetus to mature to 28 weeks, at which time an LVAD would be inserted, and a cesarean would be performed immediately thereafter. By 28 weeks the EF had improved to 25%. She was brought to the hybrid operating room and monitored with pulmonary and radial arterial catheters. Transcutaneous pacing pads were applied. Left uterine displacement was maintained throughout. Local anesthesia and fluoroscopy were used to insert an LVAD (Impella CP®, Abiomed, Danvers, MA) via the femoral artery, and ventricular support was initiated. As systemic anticoagulation precluded neuraxial instrumentation, general endotracheal anesthesia was then induced using a rapid sequence technique with lidocaine, etomidate and succinylcholine. Cesarean delivery was performed, and a female infant with APGARs of 6 and 8 was delivered. Intraoperative bradycardia and hypotension were managed with epinephrine, and episodic ventricular tachycardia was treated with lidocaine. Postoperative EF was 25-30% with significant mitral regurgitation but improved right ventricular function. She was extubated 4 hours after surgery. The LVAD was removed on postoperative day 1. Six months postpartum her EF remained 25-30% and the patient had returned to her normal activities of daily living.
Discussion: There are reports of PPCM patients with an LVAD in place prior to pregnancy, and there is a report of a patient receiving an LVAD after delivery. To our knowledge, this is the first report of an LVAD insertion during pregnancy to accommodate the physiological stress of delivery. A multidisciplinary approach was integral to coordinating her treatment.