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Tricuspid valve replacement with cardiopulmonary bypass during pregnancy: the challenge of fetal protection
Abstract Number: S4D-5
Abstract Type: Case Report/Case Series
Cardiac surgery during pregnancy presents a unique challenge to minimize the risk for adverse maternal and fetal outcomes. The physiologic changes of pregnancy further complicate the burden of cardiopulmonary bypass (CPB) which often results in morbidity or mortality to the fetus. In this case presentation, we discuss the perioperative course of a parturient requiring urgent tricuspid valve (TV) replacement with CPB.
Our patient was a 25 year old G4P3 female at 19w5d who presented with high-grade fever, chest pain and shortness of breath but denied prior cardiac history. Her medical history was significant for intravenous drug use. Blood cultures were positive for gram-positive cocci. A transthoracic echo revealed TV vegetations suggestive of endocarditis. Further workup showed likely septic pulmonary emboli with increased right heart pressures. An interdisciplinary team recommended an urgent TV repair given the high risk of cardiovascular decompensation in the context of the physiologic changes of pregnancy.
Preoperative monitoring showed no signs of fetal distress. The patient was brought to the operating room and placed supine with a left lateral tilt. An intravenous induction with aspiration precautions was uneventful and anesthesia was maintained with sevoflurane. No intraoperative fetal heart or uterine tone monitoring were obtained given the age of the fetus. MAP was maintained between 60 and 80mmHg. The FiO2 was kept at 1.0. CPB time was 90 minutes and the patient was kept normothermic. She was separated from CPB without pharmacological support. Immediately postoperatively, an abdominal ultrasound confirmed normal fetal heart tones and movement. The patient was extubated on POD 1 and transferred to the floor on POD 5.
Fetal mortality ranges from 16%-33% with CPB.1 Uterine contractions are the most common cause of fetal demise with changes in maternal pH, electrolytes, temperature and hematocrit also increasing fetal stress. Fetal bradycardia often onsets with the initiation of CPB but resolves with increased perfusion pressure and hemodynamic stabilization.2
Accepted fetal protection strategies during CPB include: 1) maintaining a pump flow rate >2.5 L/min/m2 and perfusion pressure >70 mm Hg; 2) maintaining the mother’s hematocrit >28%; 3) normothermic perfusion; 4) 15° left lateral tilt positioning; and 5) minimizing CPB time.3
Both the mother and fetus did well postoperatively. This case illustrates that the use of more stringent parameters during CPB, along with collaboration amongst multiple medical specialists may help improve fetal outcomes in the parturient undergoing cardiac surgery.
1. Patel A, et al. Cardiac surgery during pregnancy. Tex Heart Inst J. 2008;35(3):307-12.
2. Kapoor MC. Cardiopulmonary bypass in pregnancy. Ann Card Anaesth. 2014;17(1):33-9.
3. Chandrasekhar S, et al. Cardiac surgery in the parturient. Anesth Analg. 2009;108(3):777-85.