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Cesarean Section in A Parturient with Congenital Cardiomyopathy, Complicated by Ventricular Bigeminy
Abstract Number: RF1AA-49
Abstract Type: Case Report Case Series
INTRODUCTION: In the vast majority of patients with congenital cardiomyopathy the etiology is unknown. Pregnancy stresses the cardiovascular system and is therefore poorly tolerated in this population, and it carries significant risk factors; risks include overt heart failure occurring during pregnancy, irreversible deterioration in ventricular function, and the most feared complication of fetal loss or maternal death(1).
CASE: A 23-year-old G4P3003 at 39w3d with a history of congenital cardiomyopathy for repeat cesarean section (CS). Home medications included bisoprolol and hydrochlorothiazide. A peripartum transthoracic echocardiogram revealed a mildly dilated left atrium, markedly dilated left ventricle, diffuse hypokinesis and an ejection fraction of 35 %. Patient endorsed dyspnea on exertion as well as shortness of breath; NYHA Class III.
Decision was made to proceed with CS under a combined spinal epidural (CSE). Prior to CSE 2 large bore IV’s were placed, as well as left radial arterial line for hemodynamic monitoring. Two units of packed red blood cells were readily available, and a 1-liter bolus of lactated ringer’s solution was initiated. In the operating room, a CSE was placed at L4-L5. 1.2 mL of bupivacaine 0.75 %, morphine 100 mcg, and fentanyl 15 mcg were injected intrathecally. Upon placement of spinal a phenylephrine infusion was initiated. When the patient was placed supine, she became hypertensive and EKG tracing was consistent with ventricular bigeminy. Phenylephrine infusion was stopped and led to the resolution of bigeminy, which was hypothesized to be secondary to a stretch-induced arrhythmia due to the increased afterload. Patient received a one-liter bolus in lieu of vasopressors and blood pressure was maintained with a mean arterial pressure above 70. Upon delivery of the fetus patient was requiring intermittent boluses of lidocaine 2% due to increasing sensation during the procedure. The epidural was dosed slowly without hemodynamic changes and patient remained comfortable for the remainder of the CS.
DISCUSSION: There is scant information in the literature regarding the anesthetic management of parturient with congenital cardiomyopathy(1). Principles of anesthetic management are: maintenance of normal to low heart rate to decrease oxygen demand and prevention of swings in blood pressure. Upon review of literature there have been case reports describing bigeminy during phenylephrine infusion after neuraxial anesthesia, all of these resolved with discontinuation of the vasopressor(2). As women with congenital heart disease now have a higher life expectancy and are becoming pregnant, this case is an excellent example of anesthetic management in a patient who was told to avoid pregnancy due to significant morbidity and mortality.
1. Anesthesiology 2002; 97: 513-15.
2. Int J Obstet Anesth. 2007; 163:288-90