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Anesthetic Management of Aortic Stenosis in parturients: A compendium of case reports from literature
Abstract Number: T3A-6
Abstract Type: Original Research
Our report presents an up-to-date compendium of case reports reviewing peripartum anesthetic management and analyzing various complications in parturients with AS with respect to severity, NYHA class and anesthetic management.
We screened case reports from literature to review peripartum anesthetic management in parturients with AS and information on patient demographics; etiology and severity of AS; aortic valve areas and gradients; clinical symptoms and NYHA class; mode of delivery; anesthetic management; peripartum monitoring and complications were collected. According to recent European Society of Cardiology guidelines, severe AS exists when all of these are present: a valve area of <1.0 cm2; an indexed valve area of <0.6 cm2; a mean gradient of >40mmHg and a peak gradient of >64 mmHg (1). Frequency statistics were presented on the etiology and severity of AS, delivery, anesthetic management, monitoring and complications.
26 case reports (44 patients) were included, 13 with moderate AS and 31 with severe AS. 84% of the etiology was congenital; 16% had rheumatic heart disease. 54% of patients with moderate AS had no cardiac symptoms and 46% had mild symptoms. 61% of patients with severe AS had severe cardiac symptoms, 16% had mild symptoms and 23% were asymptomatic. 45% of patients with moderate AS had CD vs. 70% with severe AS. All patients with moderate AS had labor analgesia without complications. 85% of patients with moderate AS had regional anesthesia for CD and 40% had hypotension.
32% of patients with severe AS delivered vaginally and all had labor analgesia. 30% of them developed hypotension requiring vasopressors. 68% of patients with severe AS had CD, 95% were elective. 60% of patients with severe AS having CD were NYHA 3/4 class. 65% of CD were performed with GA, 25% with epidural, 5% with CSE and 5% with spinal anesthesia. Etomidate was used in 79% of patients for induction. 71% of patients with regional anesthesia for CD had adverse events. 1 patient had 2 episodes of intraoperative unstable angina and 1 patient was hypotensive after titrated epidural for CD, 1 patient was hypotensive after CSE for CD, 1 patient developed postoperative pulmonary edema after spinal for CD and 1 patient had intraoperative pulmonary hypertension after epidural anesthesia. 23% of patients with GA for elective CD had adverse events. 2 patients were hypotensive and 1 developed transient ST depression after GA for elective CD.
62% of patients with moderate AS had invasive monitoring vs. 85% with severe AS.
GA was preferred for CD in symptomatic patients, whereas regional technique was used for labor analgesia in most patients and mostly for CD anesthesia in patients with moderate AS. Invasive monitoring was more prevalent in symptomatic patients. Anesthetic management should be individualized and based on functional status and anticipated complications.
1. Eur Heart J 2012;33:2451–96.