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Cesarean Section in a Parturient with Hypertrophic Obstructive Cardiomyopathy, Severe Pulmonary Hypertension, and Suspected Accreta
Abstract Number: FCA-224
Abstract Type: Case Report Case Series
Introduction: Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by left ventricular outflow tract obstruction with a high gradient. Management includes maintaining preload, afterload, and normal sinus rhythm. Conversely, treatment of pulmonary hypertension (PHTN) involves minimizing pulmonary vascular resistance and hypervolemia while promoting right heart function. Pregnancy significantly complicates these conditions as intravascular volume and cardiac output rises during gestation and peaks immediately after delivery. We present a case of a parturient with concurrent HOCM and severe PHTN.
Case: A 31yo G4P3 parturient was admitted at 35 weeks gestation with symptoms of heart failure, IUGR, preeclampsia, and suspected placenta accreta. Past history included obesity, HTN, asthma, HOCM s/p ICD, NSTEMI, heart failure, and severe PHTN, as well as, two prior C-sections under general anesthesia. She did admit to frequent episodes of chest pain, dyspnea and syncope, and required diuresis on admission. A TTE revealed an EF 75%, severe LVH, an LVOT gradient 40mmHg, and a RVSP 81mmHg. Due to the severity of her condition, a multidisciplinary team of OB/GYN, OB/CT anesthesia, cardiology, neonatology, trauma surgery, and ICU staff was assembled to devise a plan for her delivery at 36 weeks gestation. To promote the most optimal conditions, a TIVA technique was used following RSI and intubation with etomidate, remifentanil, esmolol, and succinylcholine. Standard and invasive devices were used for monitoring and resuscitation, including an arterial line, PA catheter, and TEE. To avoid the side effects of uterotonic medications, a REBOA device was placed to manage hemorrhage. A combination of vasopressors was used to augment cardiac function with vasopressin being the most efficacious. Intra-op the pulmonary artery pressure increases to 95 mmHg, near systemic levels, and was treated with inhaled nitric oxide (iNO). Following delivery, the patient’s condition improved greatly. Vasopressors and iNO were discontinued within 24 hours and the patient was extubated. The rest of her stay was uneventful.
Conclusion: Perioperative management of this patient was especially challenging due to the comorbidities that required opposing therapeutic strategies. In all likelihood, the number of parturients with complicated heart disease will continue to grow, and therefore, the need for a comprehensive team approach for these challenging cases will remain.