Combined spinal epidural anaesthesia in a primigravida with valvular heart disease

Anesthetic Management of a Pregnant Patient With Mixed Aortic Valve Disease Undergoing Cesarean Section

Aortic stenosis is a condition with multiple etiologies that can remain clinically silent for years. The enhanced cardiovascular demands of pregnancy can unmask a previously undetected disease or worsen existing symptoms. Managing anesthesia in pregnant patients with cardiac valvular disease is a complex task that requires a coordinated, multidisciplinary approach. This case report presents a 28-year-old pregnant Hispanic patient with known severe aortic stenosis who was admitted to our hospital at 30 weeks of gestation for multidisciplinary management and delivery planning. Her only symptom was dyspnea, classified as NYHA class II. Upon admission, a transesophageal echocardiogram (TEE) revealed severe subvalvular aortic stenosis caused by a membrane and moderate aortic valve regurgitation with a preserved left ventricular ejection fraction.  Initially, a cesarean section was planned due to breech presentation. The procedure was scheduled for 34 weeks but postponed to 36 weeks of gestational age due to the patient's stable hemodynamic status. The anesthetic approach was a combined spinal-epidural technique that provided better hemodynamic stability and effective pain control and minimized the risk of broncho-aspiration and the maternal-fetal transfer of obstetric drugs associated with general anesthesia. Careful patient selection and continuous hemodynamic monitoring were essential to avoid complications and guarantee a successful outcome. This approach proved to be safe and effective for our patient. This case highlights the importance of a multidisciplinary team approach in managing pregnant patients with cardiac disease. It also demonstrated that combined spinal-epidural anesthesia is a safe and viable option for anesthesiologists caring for these patients.

Neuraxial Anesthesia in Patients With Aortic Stenosis: A Systematic Review

Neuraxial anesthesia (NA) has been contraindicated in patients with aortic stenosis (AS) due to concerns of sympathetic blockade and hemodynamic instability. These considerations are based on precautionary expert recommendations, supported by expected physiologic effects, but in the absence of any published scientific evidence. In light of the increasing elderly population and the prevalence of AS, this systematic review compiles available literature on NA in patients with AS to address the understanding of the anesthetic practice and safety in this population. Using a systematic approach, PubMed, Embase, and Web of Science were searched for studies of patients with AS who exclusively received NA. Primary outcomes included intraoperative and postoperative complications. Of 1,433 citations, 61 met full-text inclusion criteria, including 3,228 patients undergoing noncardiac (n = 3,146, 97.5%), obstetric (n = 69, 2.1%), and cardiac (n = 13, 0.4%) procedures. Significant data heterogeneity (local anesthetic dosing, intraoperative interventions, and measured outcomes) prevented formal metanalysis, but descriptive data are presented. Spinal block (n = 2,856, 88.5%) and epidural anesthesia (n = 397, 12.3%) were administered most frequently. Hypotension requiring vasopressors was the most common intraoperative complication-noncardiac (n = 16, 9.9%), obstetric (n = 6, 13.0%), and cardiac (n = 1, 7.7%)-with resolution in all patients and no reported intraoperative cardiovascular collapse or mortality. The relative risk of different AS severities remains unclear, and optimal medication dosing remains elusive. The authors' data suggested that NA may not be contraindicated in carefully selected patients with AS. The authors' results should inform the design of future prospective studies comparing NA and general anesthesia in patients with AS.

Anesthetic management of a parturient with Shone's syndrome -a case report with review of literature

BACKGROUND

Shone's syndrome is a rare complex congenital cardiac condition, characterized by a supra-valvular mitral ring, parachute deformity of the mitral valve, aortic stenosis, and coarctation of the aorta.

CASE

A 26-year-old parturient with partial Shone's syndrome presented to our delivery unit in pulmonary edema. She underwent a scheduled cesarean section performed under a combined spinal-epidural anesthetic at 33 weeks. She had multidisciplinary input from the cardiac, obstetric, and anesthetic teams, which led to a good outcome. A review of the five published case reports of Shone's syndrome in pregnancy is presented along with key findings.

CONCLUSIONS

Our case report and the review highlight the successful use of combined spinal-epidural anesthetic and provides guidance to the multidisciplinary team on the varied presentation and the optimum management of women with Shone's syndrome during the peripartum period.

[Continuous spinal anesthesia and pulmonary arterial hypertension]

We report the use of continuous spinal anesthesia for hip fracture surgery in a patient with pulmonary arterial hypertension. Preoperative evaluation, anesthetic technique and preoperative monitoring are discussed.

Anesthetic considerations for patients with advanced valvular heart disease undergoing noncardiac surgery

Patients with valvular heart disease represent a growing segment of the population and can present major challenges to clinical anesthesiologists. This review focuses on patients with advanced left-sided valvular disease undergoing noncardiac surgery. The pathophysiology and anesthetic implications of aortic stenosis and insufficiency and mitral stenosis and insufficiency are discussed, with a focus on optimizing perioperative management and decision making for patients with these conditions.

Anesthetic Considerations in the Patient With Valvular Heart Disease Undergoing Noncardiac Surgery

Valvular heart disease can be an important finding in patients presenting for noncardiac surgery. Valvular heart disease and resulting comorbidity, such as heart failure or atrial fibrillation, significantly increase the risk for perioperative adverse events. Appropriate preoperative assessment, adequate perioperative monitoring, and early intervention, should hemodynamic disturbances occur, may help prevent adverse events and improve patient outcome. This review article aims to guide the practitioner in the various aspects of anesthetic management in the perioperative care of patients with valvular heart disease. The pharmacological approach to optimization of patient outcome with drugs, such as βblockers and lipid-lowering medications (statins), is an evolving field, and recent developments are discussed in this article.

Continuous spinal analgesia for labor pain in a parturient with aortic stenosis

Aortic stenosis in pregnancy carries a high fetal and maternal morbidity and mortality. Spinal analgesia/anesthesia is considered by many to be contraindicated in these patients. The rapid onset of sympathetic block induces hypotension, which can result in myocardial hypoperfusion and myocardial ischemia. We describe a case of moderate to severe aortic stenosis, diagnosed during pregnancy, in which pain relief during labor and delivery was managed using a continuous spinal catheter. Pure intrathecal opioid analgesia was used initially to maintain hemodynamic stability. However after two bolus administrations of sufentanil, analgesia was further maintained using ropivacaine and sufentanil. A spinal catheter was chosen to provide reliable anesthesia, which could be extended rapidly for cesarean section.

[Anesthesia for cesarean section in a Marfan patient with complicated aortic dissection]

We report the anaesthetic management of a 32-year-old pregnant women with aortic dissection and Marfan syndrome for caesarean section. The patient has presented at 31 weeks gestation of a first pregnancy an aortic dissection that required an emergency aortic replacement. Three years later, she presented at 31 weeks gestation with aortic dissection, mitral valve dysfunction and acute pulmonary oedema. She was treated in intensive care unit with deslanoside, diuretic and twice a day echographic examination. Delivery was planned by caesarean section after haemodynamic stabilisation on the sixth day. Combined spinal and epidural anaesthesia was performed after monitoring. The initial intrathecal injection of bupivacaine, morphine and fentanyl provided rapid onset of analgesia. Epidural anaesthesia was used with diluted lidocaine and fentanyl boluses. With appropriate preoperative care and monitoring, uneventful combined spinal and epidural anaesthesia for Caesarean section was achieved in a patient with Marfan syndrome in the presence of aortic dissection complicated by mitral valve dysfunction and acute pulmonary oedema.

Obstetric epidural analgesia in aortic stenosis: a low-dose technique for labour and instrumental delivery

Five patients with valvular or fixed subvalvular aortic stenosis presented to a high-risk obstetric anaesthetic clinic over a 3-year period. All five were assessed during pregnancy and admitted at full term. A low-dose lumbar epidural analgesia regimen was used during labour and delivery. The use of pre-assessment and planned admission, invasive monitoring, epidural analgesia and interventional assisted delivery is discussed with reference to this patient group, and other aspects of peripartum management of concern to the anaesthetist.