Anesthesia for pregnant women with valvular heart disease: the state-of-the-art

Anesthetic Management of Cesarean Sections in Parturients with Valvular Heart Disease

Valvular heart disease during pregnancy and labor poses a significant threat to maternal and fetal outcomes, increasing morbidity. The physiological changes of pregnancy in a parturient with stenotic and regurgitant lesions increases the risk of cardiac decompensation. Moderate-to-severe stenotic lesions can deteriorate in pregnancy due to an increase in workload on the heart, leading to complications such as congestive heart failure, atrial fibrillation, and thromboembolism. Maintaining uteroplacental perfusion and systemic vascular resistance in a fixed output state is quite challenging during the perioperative period. There is no single best technique for the management of such patients for labor or cesarean section. A good understanding of the normal physiological changes with their impact on the pathophysiology and the severity of the lesion will help in successful perioperative management. We describe the anesthetic management of parturients with known valvular heart disease posted for emergencies as well as elective lower segment cesarean section.

Cardiovascular disorders in pregnancy: diagnosis and management

Cardiovascular diseases (CVDs) are a major cause of complications in pregnancy worldwide and the number of patients who develop cardiac problems during pregnancy is increasing. This review summarises recent literature on the aetiology and the underlying pathophysiology, diagnostic tools, risk stratification and prognosis in women who develop heart failure during pregnancy and in the peri-partum phase as well as in patients with pre-existing cardiomyopathies undergoing pregnancy. We specifically highlight peri-partum cardiomyopathy, valvular disease and Marfan's syndrome. Furthermore, we provide overviews on established treatment concepts and novel therapeutic strategies for these different disease types, stressing the point that pregnancy-associated cardiac disease requires interdisciplinary concepts for diagnosis, management and treatment.

Management of acquired cardiac disease in the obstetric patient

Physiologic changes incurred by pregnancy can cause severe decompensation in the parturient with underlying cardiac disease. The result is increased morbidity and mortality for both mother and child. Appropriate anesthetic management can significantly impact these outcomes. This review systematically presents the pathophysiology, peripartum risk, and anesthetic management in the puerperium of specific acquired cardiac abnormalities including: valvular disease, pulmonary hypertension, cardiomyopathy, cardiac transplantation, ischemia, arrhythmias, and cardiac arrest.

[Management of cardiac high risk pregnancy. Caesarean section in a primagravida with cyanotic cardiac defect]

A 37-year-old gravida I with cyanotic heart disease presented for caesarean section in the 31st week of gestation. Caesarean section was performed uneventfully with the patient under epidural anaesthesia accompanied by invasive monitoring. Postoperative echocardiography showed no change in the shunt fraction, volumes or the ventricular function. Every patient with complex comorbidities has to be managed according to individual prerequisites and the experiences and preferences of the team. For such high risk pregnancies regional anaesthesia seems to be a possible option although no clear evidence can be found in the literature.

Peripartum anesthetic management of patients with aortic valve stenosis: a retrospective study and literature review

BACKGROUND

Anesthetic management of parturients with aortic stenosis is controversial. Early studies suggest maternal mortality was related to cardiac condition and anesthetic care. In this report, management of parturients with moderate or severe aortic stenosis in two institutions is compared, and published cases are reviewed.

METHODS

Peripartum anesthetic management of all parturients with moderate or severe aortic stenosis who gave birth between 1990 and 2005 at our institutions, is described. Patients with mild or non-valvular aortic stenosis were excluded.

RESULTS

There were 12 parturients, six with moderate and six with severe aortic stenosis. Two patients with moderate aortic stenosis were New York Heart Association (NYHA) classification II, the others were asymptomatic. Five patients with severe aortic stenosis were symptomatic (NYHA classification II or III). Two patients with moderate and three with severe aortic stenosis underwent cesarean delivery; epidural anesthesia was used for two. Two patients with moderate and all with serious aortic stenosis were observed postpartum for 24 to 48 h in a high-dependency unit. There were no severe maternal or neonatal complications.

CONCLUSIONS

Carefully titrated regional analgesia is usually well tolerated in patients undergoing vaginal or cesarean delivery even in the presence of severe aortic stenosis. Standard monitoring is usually adequate for vaginal delivery, but invasive monitoring may facilitate management in some patients. An arterial line allows close monitoring of systemic blood pressure. Facilities for close 24-48-h post-partum observation should be available. A multidisciplinary approach is needed.

The anesthetic management for cesarean delivery in a patient with Shone's syndrome

Shone's syndrome is a rare congenital cardiac condition that consists of up to four obstructive left-sided cardiac lesions. We report a 17-yr-old nullipara with Shone's syndrome who presented for cesarean delivery. She had mild mitral stenosis and mild left ventricular outflow tract obstruction. Epidural anesthesia was attempted, but the patient developed severe hypotension associated with fetal bradycardia necessitating immediate cesarean delivery under general anesthesia. The peripartum anesthetic and management considerations for these patients are discussed.