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Anesthetic management for cesarean delivery in a parturient with repaired pulmonary atresia, ventricular septal defect and major aortopulmonary collateral arteries
Abstract Number: FCA-295
Abstract Type: Case Report Case Series
Pulmonary atresia with a ventricular septal defect and major aortopulmonary collateral arteries (PA/VSD/MAPCAs) is an extremely rare congenital malformation characterized by lack of a pulmonary valve and a pulmonary vascular bed supplied by aortopulmonary collateral arteries. Anesthetic management for cesarean delivery in these patients poses unique challenge to anesthesiologist, due to physiologic changes during pregnancy. We present a case of a parturient with corrected PA/VSD/MAPCAs who had undergone cesarean delivery under epidural anesthesia.
A 33-year-old primigravida admitted for cesarean delivery due to fetal breech presentation and maternal heart anomaly. She was diagnosed with PA/VSD/MAPCAs and underwent surgical corrections during childhood. In 1989, she underwent staged operation including left modified Blalock-Taussig shunt and left unifocalization, right ventricle (RV) to pulmonary artery (PA) conduit interposition, and palliative right ventricular outflow tract reconstruction at 4 years of age. Upon referral to our clinic, her SpO2 was measured as 80-85% on room air status. Her echocardiography revealed a large VSD with bidirectional shunt, moderate RV-PA conduit stenosis with peak velocity of 2.7 m/sec, mild to moderate pulmonary regurgitation. Her estimated left ventricular ejection fraction was 69%. Her cardiologist recommended to use diuretics and to avoid volume overload. Oxygen was supplied in order to maintain SpO2 more than 85%. A radial arterial line was placed. Then, an epidural catheter was inserted at the L3-4 intervertebral space and 3 mL of lidocaine 2% was given as a test dose. After 10 minutes, 2% lidocaine 140 mg and 0.75% ropivacaine 75mg was administered in gradual manner. A sensory block to the T6 was achieved bilaterally. Hemodynamic parameters were stable throughout the surgery and a female baby was delivered with Apgar scores 9 at 1 minute and 9 at 5 minutes. The mother was transferred to the intensive care unit for close monitoring after delivery. She remained stable and was transferred to the general ward 24 hours after delivery. She was discharged without any complications on the postoperative day 5. One month after delivery, she was examined in the cardiologic outpatient clinic, and she was doing well.
The physiologic changes associated with pregnancy can compromise parturients with PA/VSD/MAPCAs. The stress and pain during labor and delivery can increase PVR, thereby worsening right-to-left shunt. SVR is reduced throughout pregnancy and may lead to worsening of a right-to-left shunt. Surgically corrected patients may have various types of residual abnormality. Careful review of the history and consultation with the primary care physician will help understand the residual pathophysiology and plan the perioperative management. Careful titration of epidural anesthesia with the invasive arterial monitoring can be safely used in these patients.