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Use of Intraoperative TTE for a Patient with Hypertrophic Cardiomyopathy Undergoing a Cesarean Delivery with a Neuraxial Technique
Abstract Number: FCB-285
Abstract Type: Case Report Case Series
Hypertrophic cardiomyopathy (HCM) prevalence is estimated to be around 2% in the general population. It is defined as any left ventricle myocardial segment thickness ≥ 15 mm not explained by abnormal loading conditions. An instantaneous peak Doppler left ventricular (LV) outflow tract pressure gradient ≥ 30 mmHg at rest or with activity is considered obstructive. Patients with HCM are at risk of heart failure, arrhythmias and sudden cardiac death. Pregnant patients with HCM usually reach term and are at greater risk of cardiovascular complications.
We present the case of a 22 year old G1P0 patient at 37 weeks with history of HCM and an AICD admitted for cesarean delivery. She was taking 200 mg of metoprolol BID. Echocardiogram showed severe diffuse concentric LV hypertrophy, systolic anterior motion of the mitral valve leaflet with LV obstruction (maximum instantaneous gradient 125 mmHg, mean gradient 56 mmHg).
Combined spinal epidural (CSE) anesthesia was planned for cesarean delivery. Hemodynamic goals included avoiding tachycardia, maintaining preload, and maintaining afterload. Large bore peripheral intravenous access and an arterial line where placed under remifentanil infusion for anxiolysis. Transthoracic echocardiogram (TTE) monitoring was done intraoperatively in conjunction with a cardiac anesthesiologist. Prior to CSE, TTE showed adequate volume status and LV function. Fentanyl 15 mcg and morphine 100 mcg where given intrathecal followed by slow titration of epidural lidocaine 2% to obtain a T4 level. TTE was repeated to evaluate LV function and volume throughout the procedure. Intraoperative course was uneventful, 3.2 L of crystalloids were administered, and vasopressors were not required. She was monitored for 24 hours postoperatively in the ICU. She was discharged home on postoperative day 4.
In this patient with obstructive HCM, the decision for modified CSE was made to give the benefit of intrathecal opioid for postoperative analgesia and intraoperative block density, while titration of epidural local anesthetic avoided sudden sympathectomy and decreased preload and afterload. In addition, TTE was a noninvasive monitor to guide fluid administration to maintain adequate preload and prevent dynamic left ventricle obstruction.
European Heart Journal, Volume 38, Issue 35, 14 September 2017, Pages 2683–2690
European Heart Journal, Volume 35, Issue 39, 14 October 2014, Pages 2733–2779