Peripartum Anesthetic Management in Patients with Left Ventricular Hypertrabeculation
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1 Peripartum Anesthetic Management in Patients with Left Ventricular Hypertrabeculation Marissa L. Kauss, M.D. Fellow, Cardiovascular Anesthesia Mayo Clinic, Rochester, Minnesota Cardiac Problems in Pregnancy Saturday, February 24, 2018, 17:05-17:15
2 LV Hypertrabeculation (LVHT) LV non-compaction Cardiomyopathy: Prominent ventricular trabeculations Deep intertrabecular recesses directly communicating with LV cavity Heterogenous disorder composed of genetic and nongenetic risk factors Sarma et al. Progress in Card. Dis. 52;2010:
3 What trouble does this cause? 3 major sequelae Heart failure Arrhythmias LBBB (20-40%), PVCs, VT (7-26%) Thromboembolism Stroke risk 1-2%/yr
4 Need for additional monitoring? Type of analgesia? HOW DOES THIS AFFECT ANESTHETIC MANAGEMENT IN THE PARTURIENT? Post-partum management? Anesthetic choice if Cesarean delivery (CD)?
5 Methods Single institution retrospective chart review Women delivering at Mayo Clinic, MN between January October 2017 Free-text query for terms relating to LVHT Only patients meeting full Jenni criteria were included Transthoracic echocardiograms were reviewed by board-certified echocardiographer Bennett et al. Cardiol Res Pract. Vol Article ID
6 Results 5 women met inclusion criteria All 5 met LVHT criteria on MRI as well 4/5 LVHT Diagnosis was remote from pregnancy (B-E) Range: 2-7 years prior to pregnancy 2 patients had family history of cardiomyopathy 1 patient (A) diagnosed during 3rd trimester Presented with SOB and wide-complex tachycardia on EKG
7 Heart Failure ALL pre-pregnancy NYHA I 1 (C) with EF<55% prior to pregnancy Unchanged with pregnancy 1 (D) with baseline EF 58% NYHA II/III with EF 35% by 3rd trimester No recovery of EF postpartum: CRT-D placed
8 Arrhythmias 3 had PVC/VT Hx (C,D,E) 2 had previous ablations (C,E) 1 (C) admitted during 3rd trimester for increased ectopy and coupling Trial of IV lidocaine, D/C with PO mexiletine Delivery uncomplicated 1 (A) w/o h/o arrhythmia presented with widecomplex tachycardia at 32 wk GA Progressed to VT Storm despite procainamide and amiodarone infusions
9 Thromboembolism 2 (C,E) on warfarin pre-pregnancy due to arrhythmia history 1 (D) started on anticoagulation during pregnancy due to PVCs and decreased EF during pregnancy None of the patients anticoagulation status precluded possibility of neuraxial analgesia/anesthetic
10 Mode of Delivery 2 NSVD (B,E) 1 AVD with forceps (C) due to fetal late decels 2 CD 1 Breech (D) 1 maternal indications (A) 1 Spontaneous abortion at 17 weeks (E)
11 Analgesia management NSVD Fentanyl only (B) Epidural (E) Test dose: 3cc 1.5% Lidocaine + 1:200,000 Epi AVD Nitrous Oxide CD CSE (D) General Anesthesia (RSI with DL x1) (A)
12 Additional Monitors All vaginal deliveries had 5-lead EKG during active labor Arterial line used in both CD CVC with PAC utilized in CD that had maternal indications (A) 3 observed in ICU immediately postpartum (A,C,D)
13 Maternal Complications 1 (A) with complications Broken tooth due to intubation Prolonged intubation and sedation (24 hr) recurrent VT if sedation lightened IABP insertion for EF 25% with severe MR (PCWP 20mmHg) pulled after 48 hr Prolonged ICU stay ICD placed prior to D/C
14 Neonatal Complications 1 complication (A) Neonate intubated due to respiratory distress/lethargy APGARS: 1, 5 Extubated <48 hours later
15 Multidisciplinary Approach All patients with LVHT followed by cardiology TTE at baseline and 3rd trimester MFM consulted on all patients Obstetric Anesthesia consulted on 3 (B,C,D) seen in 3rd trimester
16 THM LVHT patients are at increased risk of heart failure, arrhythmias, and thromboembolism Multidisciplinary approach is essential for optimizing outcomes Various anesthetic techniques all resulted in positive outcomes
17 THANK YOU! 2015 MFMER slide # -
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1. ORYN Data (Core Measures) 2. QIO Reports 3. Data Advantage Reports 4. Surgery Review Indicators: Morbidity/Mortality Code Blue Review Autopsy Criteria Met If YES chart contains documentation of discussion