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Mother’s Day Gift is a Heart Transplant…Obstetric and Anesthetic Considerations for a Patient with Severe Peripartum Cardiomyopathy
Abstract Number: FCI-466
Abstract Type: Case Report Case Series
Case Presentation – A 31yr previously healthy nulliparous patient who presented at 38weeks gestation with shortness of breath was diagnosed with new onset of severe cardiomyopathy. The patient presented to an outside facility with 2 weeks of progressive shortness of breath and orthopnea requiring sleeping upright. She was found to have an ejection fraction of 10% and pulmonary edema and transferred to this facility. After multidisciplinary discussions regarding the patient’s severity of symptoms and an unfavorable cervix for possible induction of labor, the patient was taken for cesarean delivery. An arterial line was placed and a low dose epinephrine infusion was started prior to induction for inotropic support. A rapid sequence induction and intubation was performed with etomidate and succinylcholine. Central venous access was obtained via the right internal jugular vein. A live male child was delivered. Following delivery the volatile anesthetic discontinued, and intravenous morphine and diazepam were administered and the patient was maintained on a low dose propofol infusion and 100% oxygen. Small intermittent boluses of Pitocin 3units IV at a time were given for management of uterine tone following delivery. The patient remained intubated and was taken directly to the Cardiac Care Unit for further management of her cardiomyopathy.
Hospital Course – The patient was extubated on the following day. However, she continued to require inotropic support and ultimately an intra-aortic balloon pump was placed. There was no improvement in ejection fraction and her course was complicated by a pulmonary embolism. LVAD as a bridge to heart transplant was not possible due to heparin inducted thrombocytopenia, therefore the patient was emergently listed for a heart transplant. The patient’s hemodynamics continued to worsen requiring cannulation for VA ECMO on which she remained for many weeks while waiting for a heart transplant. She continued to have worsening pulmonary edema and underwent atrial septostomy for management of volume overload and apulsility. Two months after delivery, and the day after Mother’s Day, the patient underwent orthotopic heart transplantation. Following the transplant the patient was weaned off inotropic support and her cardiac function showed a consistent ejection fraction of 55%. She was discharged 2 weeks following her transplant.
Discussion – This case highlights the complexities in the management of peripartum cardiomyopathy. Early referral to a level 4 center is recommended. A multidisciplinary approach should determine timing and mode of delivery, and strategizing management of expected postpartum complications that include heart failure and pulmonary embolism. This case also demonstrated the value of ECMO as a bridge to heart transplant. Although recovery of cardiomyopathy is expected after delivery, this case demonstrates that cardiac function can deteriorate and ECMO and heart transplant may be required.