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Tabrizi NS, Demos RA, Schumann R, Musuku SR, Shapeton AD. Neuraxial Anesthesia in Patients With Aortic Stenosis: A Systematic Review. J Cardiothorac Vasc Anesth 2024; 38:505-516. [PMID: 37880038 DOI: 10.1053/j.jvca.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/10/2023] [Accepted: 09/21/2023] [Indexed: 10/27/2023]
Abstract
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.
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Affiliation(s)
| | | | - Roman Schumann
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA
| | | | - Alexander D Shapeton
- Veterans Affairs Boston Healthcare System, Boston, MA; Department of Anesthesia, Critical Care and Pain Medicine, Tufts University School of Medicine, Boston, MA
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Tenreiro G, Santos C, Machado E, Carneiro S. Challenging Diagnosis and Management: A Complex Case Following an Urgent Caeserean Section. Cureus 2023; 15:e49227. [PMID: 38143691 PMCID: PMC10739103 DOI: 10.7759/cureus.49227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/26/2023] Open
Abstract
Hemodynamic changes during pregnancy are physiological adaptations to fulfill new demands. Although these adaptations are often well-tolerated, they may unmask or exacerbate underlying cardiovascular conditions, posing unique challenges for medical professionals. We present a case that outlines the evaluation and treatment of a 38-year-old woman who experienced health complications shortly after undergoing a Caesarean section. A 38-year-old woman who had a previous caeserean section presented for an urgent caeserean section at 39 weeks of gestational age due to non-reassuring cardiotocography. Shortly after spinal anesthesia and misoprostol administration, she developed cyanosis, confusion, mottling skin, tachycardia, tachypnea, and hypotension. The patient's clinical presentation led to a broad differential diagnosis, including cardiovascular complications, infection, medication reactions, and hemorrhage, being the ultimate diagnosis of a case of severe aortic stenosis. Successful management involved a multidisciplinary approach and coordinated effort, particularly involving the anesthesiology team, which was pivotal in timely diagnosis and intervention. The ultimate diagnosis of severe aortic stenosis emphasized the significance of accurate and coordinated healthcare. Successful management involves collaboration between obstetric, intensive care, and cardiac care teams, highlighting the potential for improved outcomes when healthcare professionals work together in complex clinical scenarios.
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Affiliation(s)
- Gabriela Tenreiro
- Anesthesiology, Unidade Local de Saúde de Matosinhos, Matosinhos, PRT
| | - Carolina Santos
- Anesthesiology, Unidade Local de Saúde de Matosinhos, Matosinhos, PRT
| | - Elvira Machado
- Anesthesiology, Unidade Local de Saúde de Matosinhos, Matosinhos, PRT
| | - Sandra Carneiro
- Anesthesiology, Unidade Local de Saúde de Matosinhos, Matosinhos, PRT
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Outcome of Peripartum Anesthesia in Women with Valvular Disease. Rom J Anaesth Intensive Care 2020; 27:11-14. [PMID: 34056118 PMCID: PMC8158311 DOI: 10.2478/rjaic-2020-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective Maternal heart disease is one of the major causes for mortality among parturients. In our study, we surveyed 220 patients with different valvular disorders who gave birth in our medical center in the years 2012–2018. The aim of this study was to characterize various valvular pathologies and compare the results of different anesthetic approaches. Methods In this retrospective study, the computerized system and file archive were searched for maternal valvular pathologies according to the International Classification of Diseases, Ninth Revision (ICD-9). The women included in the study were defined as American Society of Anesthesiology (ASA)-II or more, who suffer from valvular heart disease. Results The most common pathology was mitral valve regurgitation (57.73% of all cardiac patients). Most women were defined as having mild insufficiency, and 82.68% had normal vaginal delivery. In 17.3% of patients who had cesarean section, the main type of anesthesia was neuraxial anesthesia (95.45%). The second most common pathology was tricuspid valve regurgitation (22.73%). Most patients (78%) had normal vaginal delivery, and epidural analgesia was used in 64.1%. A minority of cardiac patients in our study were patients with stenotic heart diseases, such as aortic stenosis, mitral stenosis and pulmonic stenosis (8.18%, 4.55%, and 1.36%, respectively). No complications were observed in the peripartum period. Conclusion The use of regional anesthesia is recommended for all valvular pathologies without exception, as we observed no cases in which the severity of cardiac condition had not allowed the use of various types of regional anesthesia, for surgery or vaginal delivery.
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Bhatia K, Eccles J, Meessala DK. Anesthetic management of a parturient with Shone's syndrome -a case report with review of literature. Korean J Anesthesiol 2020; 74:342-349. [PMID: 32434290 PMCID: PMC8342832 DOI: 10.4097/kja.20181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/18/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Kailash Bhatia
- Department of Anesthesia and Peri-operative Medicine, Manchester University Hospital NHS Foundation Trust, University of Manchester, Manchester, United Kingdom
| | - Jennifer Eccles
- Department of Anesthesia, Royal Oldham Hospital, Manchester, United Kingdom
| | - Dinesh K Meessala
- Department of Anesthesia, New Cross Hospital, Wolverhampton, West Midlands, United Kingdom
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Ducas RA, Javier DA, D'Souza R, Silversides CK, Tsang W. Pregnancy outcomes in women with significant valve disease: a systematic review and meta-analysis. Heart 2020; 106:512-519. [PMID: 32054673 DOI: 10.1136/heartjnl-2019-315859] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/17/2019] [Accepted: 12/26/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To perform a systematic review and meta-analysis of maternal/fetal outcomes in pregnant women with moderate/severe native valvular heart disease (VHD) from medium/higher Human Development Index (HDI) countries. METHODS OvidSP platform databases were searched (1985-January 2019) to identify studies reporting pregnancy outcomes in women with moderate/severe VHD. The primary maternal outcome was maternal mortality. The primary fetal/neonatal outcome was stillbirth and neonatal death. Pooled incidences and 95% confidence intervals (CI) of maternal/fetal outcomes could only be calculated from studies involving mitral stenosis (MS) or aortic stenosis (AS). RESULTS Twelve studies on 646 pregnancies were included. Pregnant women with severe MS had mortality rates of 3% (95% CI, 0% to 6%), pulmonary oedema 37% (23%-51%) and new/recurrent arrhythmias 16% (1%-25%). Their stillbirth, neonatal death and preterm birth rates were 4% (1%-7%), 2% (0%-4%), and 18% (7%-29%), respectively. Women with moderate MS had mortality rates of 1%(0%-2%), pulmonary oedema 18% (2%-33%), new/recurrent arrhythmias 5% (1%-9%), stillbirth 2% (1%-4%) and preterm birth 10%(2%-17%).Pregnant women with severe AS had a risk of mortality of 2% (0%-5%), pulmonary oedema 9% (2%-15%), and new/recurrent arrhythmias 4% (0%-7%). Their stillbirth, neonatal death and preterm birth rates were 2% (0%-5%), 3% (0%-6%) and 14%(4%-24%), respectively. No maternal/neonatal deaths were reported in moderate AS, however women experienced pulmonary oedema (8%; 0%-20%), new/recurrent arrhythmias (2%; 0%-5%), and preterm birth (13%; 6%-20%). CONCLUSIONS Women with moderate/severe MS and AS are at risk for adverse maternal and fetal/neonatal outcomes. They should receive preconception counseling and pregnancy care by teams with pregnancy and heart disease experience.
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Affiliation(s)
- Robin Alexandra Ducas
- Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David A Javier
- Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Candice K Silversides
- Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai Hospital and Univeristy Health Network, Toronto, Ontario, Canada
| | - Wendy Tsang
- Division of Cardiology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Parikh N, Parikh N. Management of anesthesia for cesarean delivery in a patient with an unruptured intracranial aneurysm. Int J Obstet Anesth 2018; 36:118-121. [PMID: 30057147 DOI: 10.1016/j.ijoa.2018.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/18/2018] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Abstract
Headaches are a common symptom during pregnancy. The thunderclap headache is a sudden onset headache reaching maximal intensity within seconds to minutes. It is typically a subarachnoid hemorrhage caused by rupture of an intracranial aneurysm or arteriovenous malformation. Physiologic changes of pregnancy, such as increased cardiac output and plasma volume, may increase the risk of aneurysmal rupture. The relationship between the mode of delivery and incidence of rupture is not well defined. In this case report, we discuss the anesthetic management for cesarean delivery of a parturient with an unruptured aneurysm, located on the left ophthalmic-internal carotid artery. The delivery options and anesthetic technique used are presented, together with a review of published literature.
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Affiliation(s)
- N Parikh
- Texas Tech University Health Sciences Center School of Medicine, 3601 4th Street, Lubbock, TX 79430, USA.
| | - N Parikh
- Texas Tech University Health Sciences Center School of Medicine, 3601 4th Street, Lubbock, TX 79430, USA
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Successful use of unilateral spinal block after failed epidural block in a patient with severe aortic stenosis. Med J Armed Forces India 2016; 72:S111-S114. [DOI: 10.1016/j.mjafi.2016.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 01/21/2016] [Indexed: 11/20/2022] Open
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Paul M, Iung B, Montravers P, Longrois D, Guglielminotti J. [Anaesthetic management of patients with bicuspid aortic valve for delivery. About two consecutive cases]. ACTA ACUST UNITED AC 2013; 32:607-10. [PMID: 23850127 DOI: 10.1016/j.annfar.2013.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
Abstract
Cardiac diseases are the second cause of non-obstetrical death during pregnancy in France. Bicuspid aortic valve is the most frequent congenital cardiac disease but its characteristics are little known. We report two consecutive cases of pregnant patients with aortic bicuspidy, one with a severe aortic stenosis and one with a severe dilatation of the ascending aorta. We describe the anaesthetic management of delivery for these two cases and summarize the current recommendations for management of this condition during pregnancy.
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Affiliation(s)
- M Paul
- Département d'anesthésie-réanimation chirurgicale, hôpital Bichat-Claude-Bernard, AP-HP, 46, rue Henri-Huchard, 75877 Paris cedex 18, France
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Mobitz Type II Atrioventricular Block Followed by Remifentanil in a Patient with Severe Aortic Stenosis. Case Rep Anesthesiol 2013; 2013:852143. [PMID: 23662214 PMCID: PMC3638572 DOI: 10.1155/2013/852143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 02/18/2013] [Indexed: 11/18/2022] Open
Abstract
Opioids have been considered for their hemodynamic stability. Remifentanil is an opioid analgesic with rapid metabolism and fast primary effect and recovery. In this paper, a very rare effect of using remifentanil along with propofol was presented. An 84-year-old male patient with severe aortic stenosis underwent general anesthesia. In order to induce anesthesia and maintain it, fentanyl, pancuronium, and propofol, along with a combination of propofol and remifentanil, were used, respectively. At beginning of remifentanil infusion, bradycardia and then Mobitz type II conduction block with a hemodynamic disorder occurred for the patient. The decreased blood pressure responded to injection of atropine and ephedrine; however, dysrhythmia only improved after cessation of remifentanil. Therefore remifentanil should be used with caution in aortic stenosis.
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Michaelson-Cohen R, Elstein D, Ioscovich A, Armon S, Schimmel MS, Butnaru A, Samueloff A, Grisaru-Granovsky S. Severe heart disease complicating pregnancy does not preclude a favourable pregnancy outcome: 15 years' experience in a single centre. J OBSTET GYNAECOL 2012; 31:597-602. [PMID: 21973131 DOI: 10.3109/01443615.2011.603064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Heart disease (HD) in pregnancy remains a major cause of non-obstetric maternal and neonatal mortality and morbidity. This study describes the outcome in 164 pregnant women with HD (158 deliveries in women in New York Heart Association (NYHA) Classes 1 and 2; 17 in NYHA Classes 3 and 4) who received good antenatal care and benefitted from a specific protocol and experience of a dedicated staff. There were no maternal or neonatal deaths; 46 women were diagnosed peripartum. Based on a sub-division into NYHA categories, and when sub-divided by HD, there were no statistically significant differences between groups with regard to maternal age, gestational age at admission or at delivery, birth weight, 5 min Apgar scores, mode of delivery (caesarean delivery), senior obstetric/anaesthesiology staff in attendance or delivery during day/working hours. There was a higher incidence of pre-term deliveries in women with rheumatic heart disease and Marfan syndrome (p = 0.06) relative to others. Babies of women with coronary heart disease had prolonged postpartum course in the NICU (p = 0.0001) and longer total hospital stays for the mother. In conclusion, well-managed, motivated mothers with HD who benefit from comprehensive antenatal care, and are managed primarily by their obstetric and anaesthesia teams, can aspire to a good outcome for themselves and their babies.
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Affiliation(s)
- R Michaelson-Cohen
- Department Obstetrics and Gynecology, Hebrew University of Jerusalem, Shaare Zedek Medical Centre, Jerusalem, Israel
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Noninvasive cardiac output monitoring during general anesthesia for Cesarean delivery in a patient with severe aortic stenosis. Can J Anaesth 2011; 58:837-41. [DOI: 10.1007/s12630-011-9537-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 06/03/2011] [Indexed: 10/18/2022] Open
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Monsalve GA, Martínez CM, Gallo T, González MV, Arango G, Upegui A, Castillo JM, González JG, Rubio J, Mojica L. Paciente embarazada con enfermedad cardiaca**El resumen de este artículo fue aceptado y presentado como póster en el 42° Congreso de la Sociedad Americana de Anestesia Obstétrica y Perinatología (SOAP), en San Antonio, Texas, Estados Unidos.12 de mayo de 2010. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2010. [DOI: 10.1016/s0120-3347(10)83007-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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