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Anesthetic Considerations for a Parturient with Aortic Stenosis and Coarctation of the Descending Aorta
Abstract Number: RF6BI-470
Abstract Type: Case Report Case Series
Presented here are anesthetic considerations for a patient with morbid obesity, aortic valve stenosis and coarctation of the descending aorta that underwent repeat cesarean section. Aortic valve stenosis and coarctation of descending aorta were discovered during the pre-op history and physical and confirmed by a bedside echo. Anesthetic options included: Slowly titrated epidural with GA as backup. The patient underwent C-section uneventfully, was observed in the ICU overnight after discharge from hospital referred to a higher level of care for further intervention on her aorta.
A 31 y/o morbidly obese G2P1 with a hx of bicuspid aortic valve (BAV) lost to follow up presented with minimal prenatal care for repeat cesarean section. Upon further investigation of the patient’s shortness of breath it was discovered that she was diagnosed with a BAV as a child, however in adulthood was lost to follow up. An echocardiogram revealed an AVA of 1.15cm2 and mean gradient of 48mmHg. In addition, turbulent blood flow was seen in her descending thoracic aorta with a narrowing lumen, concerning for coarctation. After a multidisciplinary discussion, decision was made to proceed with repeat C-section under a slowly titrated epidural anesthetic.
The patient was brought back to the OR, standard ASA monitors and a pre-induction right radial arterial line were placed. A L3-4 epidural was placed uneventfully, titrated slowly. A phenylephrine infusion was used to maintain SVR and a bedside TTE was used to assess fluid status. The patient underwent a successful cesarean delivery. The patient was transferred to the ICU under the Anesthesia service for further monitoring.
Bicuspid aortic valve has two instead of the normal three leaflets, is the most common congenital heart defect. BAV is usually asymptomatic and often found incidentally on auscultation and confirmed on echo. BAV is reported in about 50% of individuals with coarctation of the aorta.
BAV results in turbulent flow through the valve, which can increase the likelihood of calcium deposits on the valve and subsequent AS. In addition, turbulent flow causes shear stress on the aortic root and ascending aorta leading to aortic dilation and potential ascending aortic dissection and rupture. Therefore, continued monitoring of the patient is needed to evaluate aortic root ascending aorta diameters.
Severity of AS is defined using mean pressure gradients, jet velocity and valve area on echo. Anesthetic goals of AS are to maintain sinus rhythm, preload and SVR. Although spinal anesthesia is considered the best anesthetic for non-emergent C-section, it is non-titratable anesthetic and can cause SVR to drop precipitately leading to cardiovascular collapse. Therefore, epidural anesthesia is preferred. In addition, we used bedside TTE to guide fluid management of the patient.