///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Perioperative Management of Surgical Thrombectomy for Right Heart Thrombus and Pulmonary Emboli during 1st Trimester of Pregnancy

Abstract Number: FCI-299
Abstract Type: Case Report Case Series

Jon M Christensen MD1 ; Marissa L Kauss MD2

Introduction

Pulmonary embolism is the leading cause of maternal death in the developed world1. In cases of hemodynamic compromise treatment consists of systemic thrombolytic therapy, catheter-directed therapies, or surgical thrombectomy2. Surgical thrombectomy requires cardiopulmonary bypass (CPB) which poses significant risks to both the mother and fetus3. We present a patient within the first trimester requiring surgical thrombectomy for significant right heart thrombus burden including pulmonary emboli and atrial thrombus in transit.

Case Presentation

30 year old G3P2 presented with chest pain and dyspnea. Lower extremity ultrasound (US) revealed deep vein thrombosis. Transthoracic echocardiogram revealed a thrombus extending from inferior vena cava across the tricuspid valve into the right ventricular outflow tract and also a thrombus in transit across the fossa ovalis. Right ventricular (RV) function was severely reduced. Pregnancy screening was positive and US estimated gestational age (GA) at 5 weeks. Due to the large thrombus in transit and significant thrombus burden, the patient was offered emergent surgical thrombectomy and PFO closure.

General anesthesia was induced with stable hemodynamics. Transesophageal echocardiography (TEE) confirmed a large right atrial thrombus and thrombus in transit. During CPB cannulation RV function worsened and required escalating doses of epinephrine. CPB was maintained with non-pulsatile flows of 2.4 L/min/m2and mean arterial pressures over 70 mmHg. Surgically, thrombus was removed from the right atrium, foramen ovalis, pulmonary bifurcation, and the PFO was closed. The patient separated from bypass and hemodynamics remained stable with improved RV function. She had an uneventful recovery. Her B-hCG trended up only minimally however US revealed reassuring fetal heart tones. She was discharged on enoxaparin anticoagulation. Most recently she had reassuring fetal heart tones at 26 4/7 weeks gestation.

Discussion

Cardiac surgery and CPB during pregnancy pose significant risks to both the mother and fetus. Recent data reported maternal mortality of 11% which is greater than previously published. In addition, fetal mortality is estimated at 33% with higher risks in the first trimester3. CPB strategies to minimize fetal risks include using normothermic CPB, minimizing CPB times, maintaining high flow rates (2.4 L/min/m2), and mean arterial pressures greater than 70 mmHg4. This presentation will further describe this patient’s perioperative management, TEE findings, and recommendations for the parturient undergoing cardiac surgery requiring cardiopulmonary bypass.

References:

1. Marik, P. NEJM.2008;359:2025-33.

2. Dorren te Raa, G. Thrombosis Research.2009;124:1-5

3. Jha, N. Ann Thoracic Surg.2018;106:618-27

4. John, A. Ann Thoracic Surg. 2011;91:1191-7

SOAP 2019