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Cesarean Delivery in a Parturient with Repaired Aortic Coarctation and Subaortic Stenosis
Abstract Number: RF2AB-141
Abstract Type: Case Report Case Series
Introduction: Aortic coarctation accounts for roughly 7% of congenital heart disease. Following repair, recurrent coarctation and subaortic stenosis can occur putting patients at risk for heart failure, and aortic dissection. Parturients with corrected aortic coarctation with subaortic stenosis may be at significant risk for morbidity if they are unable to compensate for the increased cardiac demands of pregnancy. In addition, anesthetic planning for delivery must consider how to minimize the rapid changes in hemodynamics that may occur during neuraxial anesthesia or fluid shifts following delivery. A full understanding of the post-surgical anatomical cardiac changes and current functional status will impact the level of care required for anesthetic planning. Other considerations include utilizing L arm pressure (post-ductal) as a metric of MAP and therefore a measure of uterine blood flow. We present a case of the successful management of a parturient undergoing cesarean delivery with congenital aortic coarctation s/p repair with residual subaortic stenosis.
Case: 24 yo Spanish-speaking G1P0 at 39 weeks presented for scheduled cesarean delivery. She had an extensive cardiac history including; congenital coarctation with bicuspid aortic valve and VSD s/p four surgical repairs (no records available for review) and angioplasty for residual subaortic stenosis. At the time of her delivery, she was a NYHC II with mild dyspnea on exertion and mild peripheral edema. TTE showed intact LV function, mild LVH and elevated PA pressures (40mmHg). On the day of surgery, BPs were measured bilaterally and found to be congruent. A narcotic only CSE (15 mcg fentanyl and 150 mcg morphine PF) was performed and 2% lidocaine with epi via epidural catheter was slowly titrated to a T4 sensory level. Blood pressure (measured on L arm) was tightly controlled with IV doses of phenylephrine and epinephrine to maintain systolic BP over 110mmHg and HR <100 BPM. Estimated blood loss was 600mL, 1.2L lactated ringers was administered. Patient tolerated procedure well without any intraoperative or postoperative complications. Discussion: Pregnancy in patients with repaired congenital coarctation of the aorta is generally tolerated well but may be complicated by an increased risk of left heart failure and aortic dissection when subaortic stenosis is present. Information regarding left ventricular function and anatomy, current functional status and bilateral blood pressures may influence anesthetic management. Dual arm blood pressure monitoring, especially in cases where discordance exists may help providers manage both preload and afterload. Intraoperatively during cesarean delivery, anesthesia providers should maintain preload, (measured via BP cuff on right arm), as well as prevent afterload increases (measured via BP cuff on left arm). Fluid resuscitation should be limited to avoid LV overload in symptomatic patients and heart rate control may allow for adequate ventricular emptying. In our case, we chose to utilize an intrathecal narcotic only CSE technique with slow titration of epidural anesthesia to maintain systemic and placental blood flow and to minimize the required fluid resuscitation and possible hemodynamic stability.