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One Lung and Triple Digit PA pressures during Cesarean on a repaired Tetralogy of Fallot
Abstract Number: RF5BH-397
Abstract Type: Case Report Case Series
29 year old female at 34+3 gestation sent from clinic for worsening heart failure symptoms. Significant past medical history that included tetralogy of fallot with multiple surgical interventions that were complicated by severe pulmonary hypertension and SVT. PFT demonstrated 100% pulmonary blood flow to right lung after left PA occluded during repair of left PA pseudoaneurysm. Patient medically noncompliant with follow up or appointments.
She was admitted to cardiac ICU for optimization. Right heart catherization performed with placement of Swan-Ganz catheter by interventional cardiology via right internal jugular vein. RHC demonstrated PAP 102/34 (PVR 11.4 Wood Units) with some PA systolic pressures noted in the 120s. Epidural placed overnight to help manage contraction pain.
The plan was to perform the procedure in the Cardiac OR with CT and OB anesthesia, CTS and MFM. Round table discussion prior to patient transport was completed to discuss contingencies. Patient had PA catheter placed by cardiology at the time of the RHC. Plan included arterial line, low dose CSE, CMAC in the room along with inhaled nitric in case of GETA. Cardiac drips were prepared and the ECMO machine was in the room along with cannulation equipment that would be placed prior to delivery.
Upon arrival patient was nauseous and vomiting in hospital bed with 6L face mask with inhaled epoprostenol. Arterial line was placed followed by a low dose CSE (3.75mg hyperbaric bupivacaine + 15mcg fentanyl + 100 mcg morphine) at L3-4. Patient remained seated for 10 minutes to allow caudal spread. Phenylephrine started and the patient was placed supine in LUD for foley catheter placement. Epinephrine infusion was started prior to bolusing epidural. Patient was nauseous again and no longer tolerating facemask. Saturations dropping to 80s and SVT noted with rate 160-220 shortly thereafter. Decision to convert to GA and cannulate emergently. Patient had suprasystemic pulmonary artery pressures and decision was made to go onto VA ECMO. Cesarean delivery was performed immediately after. Baby delivered with APGARS 2/6/8 and was initially only required PPV but did end up intubated prior to transport to NICU however was extubated later that day and has had an uncomplicated NICU stay. Intrauterine oxytocin administered and EBL during the case was 600mL. She was brought to the ICU and remained on VA ECMO which she remains on at this time. Her ICU course to date has been complicated by ventilator associated pneumonia and DIC. Patient has now been unable to wean from ECMO after two weeks. It was an educational case as even with the best possible planning the unexpected might happen. It was a case where maternal safety took precedent over fetal wellbeing in the decision to transport the patient out of L&D to the cardiac tower and to be on ECMO prior to delivery.