3 European Journal of Heart Failure 2016; 18,
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1 Impella Assisted Cesarean Delivery in a 27 6/7 Weeks Gestation 30 Year Old Female with Newly Diagnosed Cardiomyopathy & Multifocal Incessant Ventricular Tachycardia Brendan J Carry, MD, Jason Costa, MD, Alex Reyentovich, MD, Shaline Rao, MD, Stephen Pan, MD, Mara Rosner, MD, Jill Westcott, MD, Francine Hughes, MD, Dan Halpern, MD, Catherine Weinberg, MD February 24, 1018
2 Background Mechanical circulatory support High-risk percutaneous coronary interventions to help prevent hemodynamic instability Treatment of cardiogenic shock in the setting of cardiomyopathy Peripartum cardiomyopathy Case series, case reports INTERMACS Registry 2 Ann Surg. 1976;183(1):1 4. Crit Care. 2011;15(2):R93. Ann Thorac Surg. 2010;89(4):1. Ann Thorac Surg. 2007;84(1): ASAIO J. 2010;56(5): Neth Heart J. 2008;16(12): European Journal of Heart Failure. 2016; 18, Circ Heart Fail. 2014;7(2):300-9.
3 ilure Association of the European Society of Cardiology Stud 3 European Journal of Heart Failure 2016; 18,
4 cc: Palpitations 30 yo caucasian woman G1P0 26 weeks pregnant Mild edema Progressive shortness of breath with exertion Intermittent episodes of palpitations increasing in duration and frequency over several weeks 4
5 No significant history Ran 1/2 marathon Prenatal vitamins NKDA Father: died of heart attack at 51yo No toxic habits Married Corporate position 5 ROS: otherwise negative
6 Vitals: 96/82, P111, RR 25, 97%RA Gen: mild distress Neck: Supple, JVD 11-12cm CVS: Irregularly irregular rhythm, 3/6 systolic murmur at apex radiating to axilla Lungs: bilateral crackles at bases Abd: Soft, gravid Ext: Warm, trace edema Neuro: A&Ox3 Exam Fetus: no signs of compromise 6
7 Labs BNP 1380 Trop <0.012 x 2 CPK MB 1.79 TSH 2.5 Lactate 2.1 ANA normal Iron studies WNL LDH
8 CXR
9 EKG Palpitations and progressive dyspnea on exertion 9
10 10 Echo
11 11
12 Hospital Course Admission (26wks): Esmolol & lidocaine (Mexiletine) Unfractionated Heparin Furosemide Day 12 (27 5/7 wks): PVCs BP 90/60s PA pressure 60/36 mmhg PCWP 35 mmhg CO 4, CI L/min/m 2 by FICK Delivery Plan Day 3: Improvement of ventricular ectopy frequency Trial of Bromocriptine causing hypotension 12 Fetus: Monitored with non stress test and biophysical profiles Steroids and Magnesium
13 Delivery Plan Cardiac output increases immediate postpartum Autotransfusion Relief of IVC obstruction Increase in venous return and stroke volume Transfer of fluid from extravascular space increases Increase risk of cardiovascular compromise Augment cardiac output Inotropes Proarrhythmic Intra-aortic balloon pump Synchronization with ventricular activity Impella 13
14 Impella CP 14
15 Impella EDV & EDP Wall Tension Mean arterial pressure Diastolic pressure Cardiac output Pulmonary capillary pressure Oxygen demand LV work Systemic perfusion Coronary blood flow RV afterload Independent of EKG stability 15 International Journal of Cardiology. 2015; 201,
16 Hospital Course Admission (26wks): Esmolol & lidocaine (Mexiletine) Unfractionated Heparin Furosemide Day 12 (27 5/7 wks): PVCs BP 90/60s PA pressure 60/36 mmhg PCWP 35 mmhg CO 4, CI L/min/m 2 by FICK Day 3: Improvement of ventricular ectopy frequency Trial of Bromocriptine causing hypotension Day 13 (27 6/7 wks): Delivery 16
17 Delivery General anesthesia Impella CR placed Sheath placed for emergent ECMO prn Flow 3.5L/min. PAP 32/16, CVP 9, CO 5 C-section with left uterine displacement Hypotensive requiring epinephrine NSVT requiring lidocaine boluses EBL 555ml Baby girl Fetus Apgars Scores: 6 & 8 at 1 & 5 mins Birthweight: 1025 g Extubated after several hours 6 hours post partum UFH through purge then gradually to full dose 17
18 v Hospital Course Admission (26wks): Esmolol & lidocaine (Mexiletine) Unfractionated Heparin Furosemide Day 12 (27 5/7 wks): Frequent PVCs with salvos BP 90/60s PA pressure 60/36 mmhg PCWP 35 mmhg CO 4, CI L/min/m 2 by FICK Day 14: Impella weaned after 36hrs Cardiac MRI Day 3: Improvement of ventricular ectopy frequency Trial of Bromocriptine causing hypotension Day 13 (27 6/7 wks): C-section Impella placed Day 15: Heart failure regiment optimized Bromocriptine x1 wk Warfarin 18 European Heart Journal 2017; 38,
19 MRI l and midlevel lateral wall of the LV, with associated extensive patchy and transmura 19
20 v Hospital Course Admission (26wks): Esmolol & lidocaine (Mexiletine) Unfractionated Heparin Lasix Day 12 (27 5/7 wks): Frequent PVCs with salvos BP 90/60s PA pressure 60/36 mmhg PCWP 35 mmhg CO 4, CI L/min/m 2 by FICK Day 14: Diuresed Impella weaned after 36hrs Day 21: Discharged!!! LifeVest wearable defibrillator Day 3: Improvement of ventricular ectopy frequency Trial of Bromocriptine causing hypotension Day 13 (27 6/7 wks): C-section Impella placed Heart failure regiment optimized Bromocriptine x1 wk Warfarin 20 European Heart Journal 2017; 38,
21 5 months post partum Mother Severe LV dysfunction Considering genetic testing for DCMP Continues to wear LifeVest wearable defibrillator Baby girl Pneumothorax and infections Discharged after 3mo 21
22 Conclusion Impella is a viable option during delivery for the gravid patient with decompensated heart failure 22
23 Thank You Team! Maternal Fetal Medicine Heart Failure Electrophysiology Cardiothoracic Surgery Anesthesia ICU/SICU NICU Nurses and Staff Dr. Elkayam 23
24 THANK YOU
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