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Optimizing the Neuraxial Approach in a Patient with a History of Cardiomyopathy and Repeated Hemodynamic Instability during Previous Cesarean Delivery.
Abstract Number: RF4AD-518
Abstract Type: Case Report Case Series
Viral cardiomyopathy results in both direct destruction of cardiomyocytes and an immune dysregulation response which may lead to cardiac failure and significant morbidity. While 50-57% of patients who present with the symptomatology of viral cardiomyopathy spontaneously resolve,14-52% will develop dilated cardiomyopathy although with a 5-year survival of 83%. Parturients with a history of viral cardiomyopathy undergoing cesarean delivery present a unique challenge to the anesthesia provider, as resolution of symptoms does not preclude these patients from subsequent cardiac complications.
Our patient is a 39 yo G4P2 at 39 weeks with a remote PMH of viral myocarditis. The patient experienced two prior cesarean deliveries which were both complicated by hemodynamic instability including hypotension and ventricular tachycardia following standard doses of intrathecally administered medications. After her second cesarean delivery she suffered an NSTEMI and was found to have an EF of 30-35% with otherwise normal cardiac vasculature via cardiac catheterization. Her LV function recovered subsequently and she remained an NYHA Class I. In preparation for her third cesarean delivery, a multidisciplinary approach was utilized, receiving input from OB/GYN, cardiology, and anesthesia teams. On the day of her planned cesarean delivery, invasive monitoring, vasopressors, cardiac ultrasound and a cardiac defibrillator were readily available. Cardiology was on standby during delivery. For operative anesthesia, an a-line was placed and a dural puncture epidural was utilized with slow and careful titration of 2% lidocaine, epinephrine, and bicarbonate and supplemental fluids and vasopressor boluses. The patient delivered via cesarean uneventfully, with stable vital signs and was monitored post-operatively with telemetry. She was discharged on POD #3 without cardiac dysfunction or symptoms.
Parturients with a known history of viral cardiomyopathy may be at significant risk for hemodynamic instability and possible arrhythmia following neuraxial anesthesia. Our patient’s history of an NSTEMI, profound hypotension, and acute decompensated heart failure after prior spinal anesthetics necessitated a multidisciplinary approach to her care. In order to mitigate rapid changes in blood pressure and heart rate, we decided to perform a dural puncture epidural with slow and careful titration of neuraxial agents. While this resulted in an uneventful delivery with minimal use of pressors, we were prepared for the treatment of potential hemodynamic collapse. Despite our patient appearing to fully recover normal cardiac function after an episode of acute viral myocarditis, it is possible that the heart may be sensitized to changes during pregnancy and the administration of neuraxial anesthetics potentially leading to significant morbidity and mortality.
Dennert, R. Et al. Eur Heart J. 2008.