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Anesthetic management of patients post cardiac transplantation undergoing cesarean delivery: a case study and literature review
Abstract Number: RF6AI-545
Abstract Type: Case Report Case Series
BACKGROUND: Rates of pregnancy post heart transplantation (HT) are increasing. Cesarean delivery (CD) rate post HT is 30%.1 Reports of anesthetic management of these patients are rare. We report the anesthetic management of CD in a patient post HT and review similar published cases.
CASE REPORT: A 36 y G1P0 presented with a history of post viral dilated cardiomyopathy requiring orthotopic HT at age 30. Post-transplant course was complicated by sepsis, acute kidney injury and chronic kidney disease, and bowel resection for ischemic colitis. Graft sinus dysfunction required permanent pacemaker insertion. In pregnancy, the patient had a pulmonary embolus requiring therapeutic anticoagulation. She was admitted at 35+3 weeks gestation for increasing exertional dyspnea and anxiety. Elective CD was performed at 36+2 weeks gestation due to severe patient anxiety. ASA monitors were applied; arterial line was deferred due to poor radial artery perfusion from prior cannulation. Aspiration prophylaxis, Lactated Ringer’s (LR) co-load, and a phenylephrine infusion were administered as combined spinal-epidural (CSE) anesthesia was performed under strict asepsis. Anesthesia was achieved with Bupivacaine 0.75% 0.9 mL, morphine 200 mcg, and fentanyl 15 mcg intrathecally. Surgical block was achieved and a female infant was delivered uneventfully. Carbetocin 100 mcg was given. Close hemodynamic parameters were followed. Two doses of 5 mL Lidocaine 2% with 1:200000 Epinephrine and one dose of 5 mL bupivacaine 0.25% were given via epidural. Blood loss was 500 mL and I L of LR was given. The patient had a planned admission to the ICU for 24 hour hemodynamic monitoring and was transferred to post-partum ward in stable condition. She was discharged on post-operative day 4.
METHODS: We screened case reports from literature to review CD anesthetic management in parturients with HT.
RESULTS: Three case reports were identified describing 5 cases.2,4,5 All received neuraxial anesthesia, two of which were spinals, two were epidurals, and one was a CSE. Only one patient had an arterial line. None had central venous access. Post-operatively, three had a planned ICU admission.
CONCLUSION: The pathophysiological changes post HT compounded by the physiology of pregnancy make anesthetic management challenging. Preload dependence, the need for direct vasoactive drugs, immunocompromise, and additional comorbidities must be recognized.3,5 Most deliver vaginally but no consensus exists for CD anesthesia. With careful titration, neuraxial anesthesia appears to be well tolerated in parturients with HT undergoing CD. Standard monitoring is usually adequate, but invasive monitoring may facilitate management. Facilities for close post-partum monitoring should be available. A multidisciplinary approach is needed.
1. Clin Transpl. 2004: 69-83
2. Anesthesiology. 1989; 71(4):618-620
3. A & A. 2012; 123(2): 402-410
4. SpringerPlus. 2016; 5: 993
5. IJOA. 2000; 9: 125-132