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Anesthetic management of a parturient with repaired truncus arteriosus and cardiac decompensation
Abstract Number: S4D-6
Abstract Type: Case Report/Case Series
Truncus arteriosus (TA) is a type of CHD where only one artery arises from both ventricles, with incidence 1/10,000 live births (1). Without surgical intervention, first-year mortality is around 80%. Pregnancy is a challenge to the cardiovascular system due to volume overload, increased cardiac output and heart rate, changes in myocardial contractility, and reduction in peripheral vascular resistance; existing cardiac dysfunction can potentially decompensate.
We report the anesthetic management of a patient with repaired TA. Her pregnancy was complicated by acute heart failure and progression of truncal valve regurgitation.
19 year old G1P0, with TA repair in infancy (closure of VSD and right ventricle to pulmonary artery conduit placement), admitted at 34 weeks of gestational age (GA) with worsening CHF.
Before conception, patient was asymptomatic. On echocardiogram (echo), ejection fraction (EF) was 40-45%, with mild truncal valve insufficiency and mild dilation of truncal root. Patient was being treated for subclinical chronic heart failure and runs of ventricular tachycardia. In first trimester patient remained asymptomatic. In second trimester her exercise tolerance decreased (NYHA II) and bilateral leg pitting edema appeared. Echo at 23 weeks GA showed EF 48%. A vaginal delivery with assisted second stage of labor was initially planned.
At 32 weeks GA, patient presented with dyspnea, orthopnea (NYHA III-IV) and worsening edema. Echo revealed progression of truncal valve insufficiency to moderate/severe, decrease in EF (20-30%), and severe left ventricular dilatation. Due to her worsening cardiac functional status, at 34 weeks GA a decision was made to proceed with cesarean section.
The anesthesia team planned for epidural placement and invasive monitoring (BP and CVP). The epidural was slowly titrated with lidocaine 2% with epinephrine and fentanyl, to reach T4 level. Patient remained hemodynamically stable without vasopressor requirement. After uncomplicated delivery, patient was transferred to ICU for overnight observation. She remained stable and was moved to postpartum unit the next day. Repeat echo at 2 weeks postpartum showed EF 28-35% and moderate truncal valve insufficiency.
Patients with repaired TA require a multidisciplinary team approach and a careful anesthesia plan to minimize perioperative maternal and fetal risks.
With medical advances the number of patients with CHD who reach childbearing age has increased and these patients can successfully carry a pregnancy to term (1).
Risk of severe truncal valve insufficiency in late term should be anticipated and it can improve spontaneously after baby delivery (1).
1) Hoendermis ES, Drenthen W, Sollie KM, Berger RM. Severe pregnancy-induced deterioration of truncal valve regurgitation in an adolescent patient with repaired truncus arteriosus. Cardiology. 2008;109(3):177-9