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Severe Aortic Stenosis with Twins: Analysis of Peripartum Anesthetic Management
Abstract Number: S4D-3
Abstract Type: Case Report/Case Series
35yo G1 presented at 35 4/7 weeks gestation for Cesarean section. Her medical history was significant for di-di twin gestation, severe aortic stenosis, AVNRT s/p RF ablation, gestational diabetes, PCOS, and morbid obesity (BMI 40.3). TTE showed a bicuspid aortic valve with mean gradient of 52mmHg, valve area of 0.73cm2, hyperdynamic biventricular systolic function (LVEF >65%), and mild/moderate LVH. Throughout pregnancy, her B-blocker dosing requirements increased due to physiologic changes of pregnancy and palpitations. At time of delivery, the patient’s exercise tolerance decreased to 4-5 min of walking on a level surface, and she required 4 pillows for orthopnea.
Pre-operative delivery planning occurred at a multidisciplinary care conference involving MFM, NICU, CT surgery, and OB, Critical Care, and Cardiovascular Anesthesiology. Risks and benefits of neuraxial anesthesia (slowly titrated epidural) vs. general anesthesia were discussed. General anesthesia was chosen as the patient was unable to lie flat due to shortness of breath, and to avoid the risk of rapid intra-op conversion to general anesthesia. General anesthesia also provided improved ability to regulate respiratory and cardiovascular hemodynamics during Cesarean with large volume autotransfusion due to multiple gestation in the setting of a fixed stenotic heart lesion.
Operative Cesarean delivery proceeded in a CT OR. A radial arterial line was placed prior to rapid sequence induction, and general anesthesia was induced with fentanyl, lidocaine, etomidate, and succinylcholine. Phenylephrine was administered during induction to maintain SVR, with esmolol available to avoid tachycardia. Intubation occurred via video laryngoscopy. A rapid infusion catheter was placed to allow for large volume transfusion, and to allow for preload reduction via intentional hemorrhage following autotransfusion if right-sided heart failure or pulmonary edema ensued. Femoral arterial access for ECMO was obtained at the request of CT surgery in the event of heart failure or severe pulmonary edema. Anesthesia was maintained with a propofol drip to avoid decreased uterine tone with inhalational anesthetics, and a phenylephrine drip was utilized to maintain SVR. TEE was performed to monitor cardiovascular status during the procedure. She tolerated the procedure well with 1.5L EBL. Patient required volume resuscitation with 1 unit pRBC and 2L crystalloid. She was extubated in the OR and taken to the SICU for monitoring.
The postpartum course was complicated by chest and left arm pain POD 2 in the setting of tachycardia (HR 110s) and normotension. EKG showed ST depression in the anterolateral leads and TPN was 0.21. She was diagnosed with demand ischemia and her B-blocker dose was increased. Troponin decreased following HR control. She was discharged on POD 5 with B-blocker and furosemide. TTE one month postpartum found normal biventricular systolic function and decreased mean aortic gradient (34mmHg).