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Anesthesia management in pregnant patients with Ebstein anomaly
Abstract Number: T1C-202
Abstract Type: Original Research
Ebstein’s anomaly (EA) is a rare congenital cardiac disease characterized by malformation of the tricuspid valve leaflets and right ventricle. Obstetric, cardiac, and anesthetic concerns in pregnant patients with EA include development of congestive heart failure, intrapartum arrhythmia, embolic events, preterm delivery and fetal or neonatal death. Few reports are available in the literature in regards to anesthetic management for these patients. (1,2)
The Mayo Clinic Medical Records Database was utilized to identify pregnant patients with known EA who delivered at Mayo Clinic from January 2000 to December 2018. Medical records were reviewed to evaluate peri-partum care with a focus on anesthetic management.
During the study period, a total of 10 deliveries among 7 patients were identified. Five patients had surgically corrected EA; 4 (57%) had persistent moderate to severe right ventricular enlargement with reduced systolic function on first trimester echocardiogram; 3 (42%) had preexisting cardiac arrhythmias. All deliveries except one received neuraxial analgesia: 2 (28%) epidural, 1 (14%) combined spinal– epidural, 1 (14%) dural puncture epidural, 1 (14%) continuous spinal anesthetic after an unintended dural puncture (UDP), 4 (57%) spinal for elective cesarean delivery (CD). Two patients undergoing vaginal delivery had continuous ECG monitoring. Invasive arterial blood pressure monitoring was used in two CDs and in one forceps assisted vaginal delivery. Four patients had anesthetic and obstetric complications including placental abruption, postpartum hemorrhage, post-dural puncture headache, worsening congestive heart failure (CHF) and arrhythmias. Five patients were admitted to the intensive care unit for post-delivery monitoring. No fetal or maternal deaths occurred.
In our cohort, a significant number of patients had moderate to severe right ventricular failure. Cardiac events included CHF and arrhythmias, obstetric events included placental abruption and postpartum hemorrhage, and anesthetic events included an UDP requiring an epidural blood patch. Although patients with EA can have significant right ventricular failure, their obstetric and anesthesia outcomes appear superior to patients with right ventricular failure as a result of pulmonary hypertension.
1) Lima FV et al. Arch Cardiovasc Dis 2016. 109: 390-8
2) Ross FJ et al. Semin Cardiothorac Vasc Anesth 2016, 20(1) 82–92