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The utility of transthoracic echocardiogram in a 40-year-old female with obstructive hypertrophic cardiomyopathy under neuroaxial anesthesia for cesarean delivery
Abstract Number: RF1AA-82
Abstract Type: Case Report Case Series
Introduction: Obstructive hypertrophic cardiomyopathy (HOCM) carries a significant risk of mortality during pregnancy.1
Case Presentation: A 40-year-old 80 kg G5P3 female with a history of syncopal HOCM presents for elective primary cesarean section (c/s) at term. Initial transthoracic ECHO (TTE) was notable for left ventricular hypertrophy (LVH) without evidence of systolic anterior motion (SAM) or mitral regurgitation (MR). At 14 weeks gestation age (GA) TTE was positive for SAM and mild MR; at 24 weeks TTE was notable for mild resting left ventricular outflow (LVOT) obstruction and worsening LVH; at 34 weeks GA TTE showed moderate MR and severe diastolic dysfunction. During her pregnancy the patient (pt) required two hospitalizations for worsening LVOT obstruction symptoms due to dehydration and was followed by obstetrics, cardiology and anesthesia.
At 37 weeks GA the pt underwent a scheduled primary c/s with TTE and arterial line guidance. A combined spinal-epidural (CSE) was placed and hyperbaric bupivacaine, fentanyl and morphine was given. Concurrently, a phenylephrine infusion started and fluid boluses were administered. The patient remained hemodynamically stable; incision to delivery time: 6 minutes; estimated blood loss: 800ml.
Discussion: Pre-pregnancy symptoms are significant in predicting the deterioration of women with HOCM.2 Given our pts history of syncope and severe diastolic dysfunction her risk of maternal complications was > 20%.3 Accordingly TTE was used to visualize our pts cardiac function and aid in resuscitation after the placement of a combined-spinal. Previously, the use of CSE was avoided in women with HOCM due to the blockade of sympathetic tone.1 Recent reports however have shown CSE-associated hypotension can be minimized when TTE is used to assist in clinical decisions. 1 This case provides additional evidence that CSE is a safe approach for women with HOCM and further highlights the utility of intraoperative TTE.
1. DesRoches JM, et al. Anesthetic Management Guided by Transthoracic Echocardiography During Cesarean Delivery Complicated by Hypertrophic Cardiomyopathy. A & A case reports. 2016;6(6):154-159.
2. Ferguson EA, et al. Hypertrophic cardiomyopathy and caesarean section: intraoperative use of transthoracic echocardiography. Int J Obstet Anesth. 2006;15(4):311-316.
3. Silversides CK, et al. Pregnancy Outcomes in Women With Heart Disease: The CARPREG II Study. J Am Coll Cardiol. 2018;71(21):2419-2430.