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Noninvasive Cardiac Output Monitoring in Fontan Parturient
Abstract Number: RF7B10-407
Abstract Type: Case Report Case Series
Non-invasive cardiac output monitoring (NICOM), utilizing bioreactance, provides for a lower risk alternative to an invasive pulmonary artery catheter (PAC) in monitoring cardiac function. (1,2). The Fontan procedure is a staged procedure allowing the pulmonary circulation to adjust to increased volume in palliation of congenital heart conditions presenting with univentricular physiology. While often delivering prematurely secondary to IUGR, these patients are at high risk for complications, such as arrhythmias and worsened heart failure. We present a case using NICOM in a parturient undergoing emergent cesarean section with a history of Fontan procedure.
The patient is a 29 year-old parturient gravida 1, with heterotaxy syndrome, dextrocardia, repaired transposition of the great arteries with large ventricular-septal defect (VSD) and tricuspid atresia status post Fontan procedure. She was admitted at 31 weeks after fetal sonogram showed intrauterine growth restriction (IUGR), with planned cesarean section (CS) at 34 weeks. Baseline transthoracic echocardiogram (TTE) showed an ejection fraction (EF) of 40%, and a right-sided left ventricle connected via a VSD to the right ventricle. TTE at 32 weeks revealed reduced EF to 30%, prompting CS.
With the patient in the operating room, a lumbar epidural catheter was placed and dosed slowly with 2% lidocaine, while a radial arterial line and femoral central line were inserted. Using a Cheetah NICOM, baseline values were cardiac index (CI) 3.3, stroke volume variation (SVV) 44, and stroke volume index (SVI) 13. NICOM values were trended during the case, down to nadir of CI 2.4, SVV 35, SVI 14. CI was responsive to fluid boluses, with ending NICOM values notable for CI 3.2, SVV 44, SVI 16. The case was uneventful and the patient was brought to ICU.
NICOM aids with close intraoperative monitoring of intravascular volume. Maintaining euvolemia in Fontan patients is vital as their cardiac output (CO) is entirely dependent on pulmonary blood flow. Hypovolemia results in decreased CO, while hypervolemia often precipitates heart failure symptoms. The anatomy of Fontan patients prohibits use of a PAC. Our case exhibits the utility in the use of NICOM is managing the complex physiology of parturients with congenital cardiac abnormalities.
1. Marik, P.E. (2013). Noninvasive Cardiac Output Monitors: A State-of-the-Art Review. J Cardiothorac Vasc Anes. 27(1):121-134
2. Mehta Y, Arora D. Newer methods of cardiac output monitoring. World J Cardiol. 2014;6(9):1022-9.
3. Monteiro, R.s., et al. “Anaesthetic Management of Parturients with Univentricular Congenital Heart Disease and the Fontan Operation.” Int J Obst Anes, vol. 28, 2016, pp. 83–91., doi:10.1016/j.ijoa.2016.08.004.