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Anesthetic Management of a Parturient with a Stenotic Right Ventricle to Pulmonary Artery Conduit
Abstract Number: RF1AA-111
Abstract Type: Case Report Case Series
The patient is a 21-year-old nulliparous female at 34 weeks gestation with history of a repaired Tetralogy of Fallot (TOF) who presented to our institution in preterm labor. Her condition was complicated by pulmonary atresia with a stenosed interface of the right ventricle to pulmonary artery (RV-PA) conduit, pulmonary arterial hypertension secondary to vascular remodeling, and chronic RV systolic failure. The extent of her disease placed her in the WHO class IV maternal risk stratification. A collaborative discussion between anesthesiology, maternal-fetal medicine, cardiology, and pulmonology determined that the safest plan was for the patient to avoid painful labor contractions and Valsalva maneuvers by implementing early epidural analgesia for a forceps-assisted vaginal delivery (FAVD). A lumbar epidural was placed and tested with 5 mL of 1% lidocaine to rule out intrathecal placement and 100 mcg of fentanyl to rule out intravascular placement, and a fentanyl 2mcg/mL-bupivacaine 0.0625% infusion was started. A right radial arterial catheter was placed for hemodynamic monitoring, and a right internal jugular central line was placed for central venous pressure monitoring and resuscitation. Defibrillating pads were placed on the patient and ACLS equipment and drugs were readily available. The patient underwent FAVD in the operating room after 10 hours of labor. Estimated blood loss was 550 mL. The patient received a total of 3000 mL of crystalloid. Post-partum, the patient remained hemodynamically stable without any signs or symptoms of right heart failure.
This case demonstrates that the optimal approach to managing a laboring cardiac obstetric patient often involves the utilization of neuraxial analgesia as pain control to prevent catecholamine surges and increased cardiac stress. Avoiding an intrathecal dose limits a sudden decrease in systemic vascular resistance which can cause decreased preload, leading to decreased cardiac output. Epinephrine-containing solutions are avoided during the test dose to avoid the potential risk of tachyarrhythmias. Nitrous oxide is not an acceptable alternative as it increases pulmonary vascular resistance. Afterload increases can also be prevented by utilizing FAVD without Valsalva, or Cesarean delivery with an epidural. Strict fluid management in these patients is essential as further fluid loading may lead to worsening of right ventricular function. Our case report illustrates that as advancements develop for congenital heart disease, anesthesiologists need to be prepared to manage these patients in any perioperative setting.
1. Canobbio MM, et al: Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2017; 135: e50-e87
2. Arendt KW, et al: A case series of the anesthetic management of parturients with surgically repaired tetralogy of Fallot. Anesth Analg 2011; 113: 307-17