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Anesthetic Management of Atrial Myxoma Resection in the Second Trimester
Abstract Number: FCI-97
Abstract Type: Case Report Case Series
A healthy 23 year old G2P0 at 14 weeks of gestation presented with complaints of shortness of breath and dyspnea on exertion for 2 months. Transthoracic echocardiography demonstrated a 3 x 5 cm mass in the left atrium consistent with an atrial myxoma that prolapsed through the mitral valve resulting in functional mitral stenosis (Figure). Following a multidisciplinary meeting with cardiology, cardiothoracic surgery, maternal-fetal medicine, and anesthesia, surgical resection was recommended given that the increasing cardiac output associated with progression of pregnancy was likely to exacerbate the functional mitral stenosis associated with the patient’s already symptomatic lesion.
The patient underwent surgical removal of the mass at 14w3d of gestation. Anesthesia was induced with propofol and sufentanil and maintained with isoflurane and a low dose propofol infusion. High pump flows were used with a cardiac index of 2.4 L/min/m2. Phenylephrine was used to maintain a mean arterial pressure ≥70 mm Hg and the patient’s temperature was maintained ≥35 C. Given the gestational age, fetal heart tones were not monitored intraoperatively, but were monitored immediately postoperatively and daily during her admission. The patient was discharged on post-operative day 4 and was doing well at her most recent follow up appointment.
Cardiac surgery during pregnancy is rare and is thought to carry a significant risk to the fetus, with a fetal loss rate estimated at 33% and a 28% risk of preterm delivery (1). While data to guide anesthetic management of cardiac bypass is sparse, normothermia, high pump flow, and increased perfusion pressure (≥ 70 mm Hg) are recommended (2). Pulsatile flow may improve placental perfusion, and we considered utilization of an intraaortic balloon pump while on bypass to provide an element of pulsatility (3), but ultimately decided that the unproven benefits of pulsatile flow were outweighed by the potential maternal risks. Cardiac myxomas during pregnancy are rare with 51 cases reported (4), the majority of whom underwent surgical resection with favorable maternal and neonatal outcomes. While we do not yet have fetal outcomes for this case, it adds to the literature of favorable maternal outcomes following surgical resection of atrial myxoma during pregnancy.
1:Jha et al Ann Thorac Surg 2018
2:Chandrasekhar et al A&A 2009
3:Willcox et al J Extra Corpor Technol 2005
4:Yuan Rev Bras Cir Cardiovasc 2015