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A Patient with ARVD Undergoing Uncomplicated Vaginal Delivery
Abstract Number: T2D-6
Abstract Type: Case Report/Case Series
Arrhythmogenic right ventricular dysplasia (ARVD) is a condition that predisposes to ventricular arrhythmias leading to sudden cardiac death, as well as myocardial infiltration eventually causing cardiomyopathy and heart failure requiring transplant or mechanical circulatory support.
A 23 year-old G1P0 patient with a history significant for ARVD visited her obstetrician with the primary complaint of amenorrhea, and was found to be pregnant. Her care was then transferred to our center for high-risk care. As a child, due to a family history of sudden cardiac death in a maternal uncle, both she and her mother underwent cardiac evaluation and the patient was found to have ARVD. She had an ICD placed for primary prevention at age 17, and had several shocks over the next 5 years due to ventricular arrhythmias. She underwent a cardiac ablation in 2015, and has since experienced fewer shocks. She also underwent an ICD generator change due to a depleted battery prior to pregnancy. Her other history was significant for opiate use disorder, in remission for 20 months.
Her cardiac exam was otherwise unremarkable, and a transthoracic echocardiogram revealed normal left ventricular systolic function with moderate to severe right ventricular dysfunction and dilation, with no significant valvular abnormalities. A cardiac MRI corroborated these findings, with a moderately dilated RV with moderate to severe RV dysfunction seen on MRI. Her exercise tolerance was unlimited, and she never experienced chest pain or shortness of breath.
Her obstetrician had recommended an induction at 39 weeks' gestation and sent her to our clinic for antepartum consultation. We recommended an early epidural catheter placement and arterial catheter placement. Our electrophysiology service was consulted for her management, as was cardiac surgery due to the potential need for mechanical circulatory support in the postpartum period.
Her induction took place in one of our monitored cardiac labor rooms. We placed an uncomplicated radial arterial line using ultrasound given her history of multiple arterial catheterizations in the past. After this was performed, an epidural catheter was placed using the dural-puncture epidural technique. Test dose was performed with 5mL of 2% lidocaine (without epinephrine) in divided doses, which was negative for intravascular or intrathecal catheter. Regular bedside echocardiograms were performed by our team to assess for ventricular function and volume status. Her induction proceeded uneventfully, and she did not require diuresis or inotropic support after delivery despite her poor RV function.
This case illustrates the feasibility of an uncomplicated peripartum course in a patient with a severe cardiac condition at high risk for decompensation. The collaboration of maternal-fetal medicine, electrophysiology, cardiac and obstetric anesthesiology and cardiothoracic surgery were instrumental to this patient's safety and success during her delivery.