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Management of Parturient with Refractory Atrial Flutter
Abstract Number: RF2AB-256
Abstract Type: Case Report Case Series
The cardiovascular system undergoes significant changes during pregnancy including increased heart rate, plasma catecholamines, and adrenergic sensitivity. It is not surprising that more than 50% of pregnant women develop palpitations during pregnancy. Sustained tachycardias in these patients are rare. Patients who develop arrhythmias are challenging to manage for all teams involved and require a multidisciplinary approach for safe and appropriate management.
Our patient is a 39-year-old female G1P0 with past medical history significant for super morbid obesity (BMI 58) and chronic hypertension who presented at 22 weeks with complaints of dyspnea and chest pain. An EKG was obtained showing a narrow complex tachycardia with a rate of 170bpm without ST or T wave changes. Rate control with beta blockers was unsuccessful. Adenosine was then administered which revealed atrial flutter with a 2:1 conduction. She was started on diltiazem without improvement. Echo was significant for an ejection fraction (EF) of 30%. Despite medical therapy, the patient continued to be in atrial flutter. After 48 hours of anticoagulation, she underwent direct current cardioversion (DCCV). Anesthesia was induced with rapid sequence intubation (RSI) and maintained with propofol infusion. Successful cardioversion was achieved with an improvement in her EF to 55%. She was sent home on sotalol and enoxaparin.
One month later, the patient presented again with atrial flutter. A second DCCV was done; however, the patient failed permanent conversion. Her case was reviewed by our multidisciplinary team and it was agreed, she should undergo cardiac ablation. Anesthesia was induced with RSI and maintained with propofol and remifentanil infusions. Given her history, it was recommended she continue sotalol for the duration of pregnancy and had no further symptomatology. She was induced at term and ultimately had a cesarean section for arrest of labor under epidural anesthesia without complication.
The presentation of atrial flutter during pregnancy is the same as in nonpregnant patients. Palpitations may be associated with syncope, dyspnea, and chest pain. Pharmacologic conversion is initially attempted in stable patients whereas DCCV should be the initial treatment of unstable patients. Management during pregnancy has traditionally relied heavily on pharmacological interventions as procedural interventions carry higher risk. This paradigm is changing as newer techniques of cardiac ablation are being found to be safe and effective during pregnancy. The most important factor in safe and effective care for these patients is a multidisciplinary approach across numerous specialties.
1. Continuing Education in Anaesthesia Critical Care & Pain, Volume 9, Issue 2, 1 April 2009, Pages 44–47
2. Incidence of arrhythmias in normal pregnancy and relation to palpitations, dizziness, and syncope. Am J Cardiol. 1997 Apr 15;79(8):1061-4. Shotan et al.