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Zhang Q, Zhu F, Shi G, Hu C, Zhang W, Huang P, Zhu C, Gu H, Yang D, Li Q, Niu Y, Chen H, Ma R, Pan Z, Miao H, Zhang X, Li G, Tang Y, Qiao G, Yan Y, Zhu Z, Zhang H, Han F, Li Y, Lin J, Chen H. Maternal Outcomes Among Pregnant Women With Congenital Heart Disease-Associated Pulmonary Hypertension. Circulation 2023; 147:549-561. [PMID: 36780387 DOI: 10.1161/circulationaha.122.057987] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Studies focused on pregnant women with congenital heart disease (CHD)-associated pulmonary hypertension (PH) are scarce and limited by small sample sizes and single-center design. This study sought to describe the pregnancy outcomes in women with CHD with and without PH. METHODS Outcomes for pregnant women with CHD were evaluated retrospectively from 1993 to 2016 and prospectively from 2017 to 2019 from 7 tertiary hospitals. PH was diagnosed on the basis of echocardiogram or catheterization. The incidence of maternal death, cardiac complications, and obstetric and offspring complications was compared for women with CHD and no PH, mild, and moderate-to-severe PH. RESULTS A total of 2220 pregnant women with CHD had completed pregnancies. PH associated with CHD was identified in 729 women, including 398 with mild PH (right ventricle to right atrium gradient 30-50 mm Hg) and 331 with moderate-to-severe PH (right ventricle to right atrium gradient >50 mm Hg). Maternal mortality occurred in 1 (0.1%), 0, and 19 (5.7%) women with CHD and no, mild, or moderate-to-severe PH, respectively. Of the 729 patients with PH, 619 (85%) had CHD-associated pulmonary arterial hypertension, and 110 (15%) had other forms of PH. Overall, patients with mild PH had better maternal outcomes than those with moderate-to-severe PH, including the incidence of maternal mortality or heart failure (7.8% versus 39.6%; P<0.001), other cardiac complications (9.0% versus 32.3%; P<0.001), and obstetric complications (5.3% versus 15.7%; P<0.001). Brain natriuretic peptide >100 ng/L (odds ratio, 1.9 [95% CI, 1.0-3.4], P=0.04) and New York Heart Association class III to IV (odds ratio, 2.9 [95% CI, 1.6-5.3], P<0.001) were independently associated with adverse maternal cardiac events in pregnancy with PH, whereas follow-up with a multidisciplinary team (odds ratio, 0.4 [95% CI, 0.2-0.6], P<0.001) and strict antenatal supervision (odds ratio, 0.5 [95% CI, 0.3-0.7], P=0.001) were protective. CONCLUSIONS Women with CHD-associated mild PH appear to have better outcomes compared with women with CHD-associated moderate-to-severe PH, and with event rates similar for most outcomes with women with CHD and no PH. Multimodality risk assessment, including PH severity, brain natriuretic peptide level, and New York Heart Association class, may be useful in risk stratification in pregnancy with PH. Follow-up with a multidisciplinary team and strict antenatal supervision during pregnancy may also help to mitigate the risk of adverse maternal cardiac events.
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Affiliation(s)
- Qian Zhang
- Department of Cardiothoracic Surgery, Heart Center (Q.Z., F.Z., G.S., C.H., R.M., Y.Y., Z.Z., H.Z., Huiwen Chen), China
| | - Fang Zhu
- Department of Cardiothoracic Surgery, Heart Center (Q.Z., F.Z., G.S., C.H., R.M., Y.Y., Z.Z., H.Z., Huiwen Chen), China.,Shanghai Children's Medical Center, Department of Surgical Oncology, Shanghai Lung Cancer Center, Shanghai Chest Hospital (F.Z.), China
| | - Guocheng Shi
- Department of Cardiothoracic Surgery, Heart Center (Q.Z., F.Z., G.S., C.H., R.M., Y.Y., Z.Z., H.Z., Huiwen Chen), China
| | - Chen Hu
- Department of Cardiothoracic Surgery, Heart Center (Q.Z., F.Z., G.S., C.H., R.M., Y.Y., Z.Z., H.Z., Huiwen Chen), China.,Department of Cardiovascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China (C.H.)
| | | | - Puzhen Huang
- Shanghai Jiao Tong University School of Medicine (P.H., Z.P.), China
| | - Chunfeng Zhu
- Department of Obstetrics and Gynecology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, China (C.Z., F.H.)
| | - Hong Gu
- Department of Pediatric Cardiology (H.G., Q.L.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Dong Yang
- Department of Obstetrics and Gynecology (D.Y., X.Z., Y.L.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Qiangqiang Li
- Department of Pediatric Cardiology (H.G., Q.L.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Yonghua Niu
- Department of Ultrasound (Y.N.), Renji Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Hao Chen
- Department of Cardiology, Heart Center (Hao Chen), China
| | - Ruixiang Ma
- Department of Cardiothoracic Surgery, Heart Center (Q.Z., F.Z., G.S., C.H., R.M., Y.Y., Z.Z., H.Z., Huiwen Chen), China
| | - Ziyi Pan
- Shanghai Jiao Tong University School of Medicine (P.H., Z.P.), China
| | - Huixian Miao
- Department of Obstetrics and Gynecology (J.L., H.M.), Renji Hospital, Shanghai Jiao Tong University School of Medicine, China.,Department of Gynecology, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing First Medical University, China (H.M.)
| | - Xin Zhang
- Department of Obstetrics and Gynecology (D.Y., X.Z., Y.L.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Genxia Li
- Department of Obstetrics, Third Affiliated Hospital of Zhengzhou University, Henan, China (G.L.)
| | - Yabing Tang
- Department of Obstetrics Section 3, Hunan Provincial Maternal and Child Health Care Hospital, China (Y.T.)
| | - Guyuan Qiao
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, China (G.Q.)
| | - Yichen Yan
- Department of Cardiothoracic Surgery, Heart Center (Q.Z., F.Z., G.S., C.H., R.M., Y.Y., Z.Z., H.Z., Huiwen Chen), China
| | - Zhongqun Zhu
- Department of Cardiothoracic Surgery, Heart Center (Q.Z., F.Z., G.S., C.H., R.M., Y.Y., Z.Z., H.Z., Huiwen Chen), China
| | - Hao Zhang
- Department of Cardiothoracic Surgery, Heart Center (Q.Z., F.Z., G.S., C.H., R.M., Y.Y., Z.Z., H.Z., Huiwen Chen), China
| | - Fengzhen Han
- Department of Obstetrics and Gynecology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, China (C.Z., F.H.)
| | - Yanna Li
- Department of Obstetrics and Gynecology (D.Y., X.Z., Y.L.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China
| | - Jianhua Lin
- Department of Obstetrics and Gynecology (J.L., H.M.), Renji Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Huiwen Chen
- Department of Cardiothoracic Surgery, Heart Center (Q.Z., F.Z., G.S., C.H., R.M., Y.Y., Z.Z., H.Z., Huiwen Chen), China.,Clinical Research Center (Huiwen Chen), China.,Guizhou Branch (Huiwen Chen), China
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Boyers S, Nayyar R, Melov SJ, Tanous D, Brown J. A case series describing the multidisciplinary management of pulmonary arterial hypertension in pregnancy: Time for optimism. Aust N Z J Obstet Gynaecol 2023; 63:66-73. [PMID: 35699259 DOI: 10.1111/ajo.13557] [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: 12/24/2021] [Accepted: 05/20/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a high-risk condition during pregnancy, with recent literature describing mortality rates of up to 23%. AIM To describe the course and outcomes of pregnancy for women with PAH in a major Australian metropolitan referral centre over a 15-year period. METHODS Retrospective review of medical records of all pregnant women with PAH over the period 2005-2020. RESULTS We report the outcomes of nine pregnancies in six women. In five women, seven pregnancies proceeded to term with birth of a healthy neonate, five vaginal births and two caesareans. Two women opted for a termination of pregnancy in the first trimester following counselling. The planning of care and patient-centred decision-making was individually tailored by a multidisciplinary team. The pulmonary hypertension clinic provided specialist support including the management of pulmonary vasodilators. All women who delivered a live offspring received neuraxial anaesthesia. CONCLUSIONS Women with this condition are ideally managed in a centre with expertise in PAH; counselling regarding the risks is imperative. Regional anaesthesia, irrespective of the mode of delivery, facilitated safe delivery and improved patient experience. The option of aiming for a term vaginal birth needs to be considered in these complex women.
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Affiliation(s)
- Samuel Boyers
- Department of Anaesthesia & Perioperative Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Roshini Nayyar
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sarah J Melov
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, Reproduction and Perinatal Centre, University of Sydney, Sydney, New South Wales, Australia
| | - David Tanous
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Jane Brown
- Department of Anaesthesia & Perioperative Medicine, Westmead Hospital, Sydney, New South Wales, Australia
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Kariyawasam S, Brown J. Pulmonary arterial hypertension in pregnancy. BJA Educ 2023; 23:24-31. [PMID: 36601027 PMCID: PMC9805939 DOI: 10.1016/j.bjae.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
| | - J. Brown
- Westmead Hospital, Sydney, NSW, Australia
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4
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Zhang A, De Gala V, Lementowski PW, Cvetkovic D, Xu JL, Villion A. Veno-Arterial Extracorporeal Membrane Oxygenation Rescue in a Patient With Pulmonary Hypertension Presenting for Revision Total Hip Arthroplasty: A Case Report and Narrative Review. Cureus 2022; 14:e28234. [PMID: 36158355 PMCID: PMC9488858 DOI: 10.7759/cureus.28234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 12/01/2022] Open
Abstract
Patients with pulmonary hypertension (PH) are at an increased risk of perioperative morbidity and mortality when undergoing non-cardiac surgery. We present a case of a 57-year-old patient with severe PH, who developed cardiac arrest as the result of right heart failure, undergoing a revision total hip arthroplasty under combined spinal epidural anesthesia. Emergent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was undertaken as rescue therapy during the pulmonary hypertensive crisis and a temporizing measure to provide circulatory support in an intensive care unit (ICU). We present a narrative review on perioperative management for patients with PH undergoing non-cardiac surgery. The review goes through the updated hemodynamic definition, clinical classification of PH, perioperative morbidity, and mortality associated with PH in non-cardiac surgery. Pre-operative assessment evaluates the type of surgery, the severity of PH, and comorbidities. General anesthesia (GA) is discussed in detail for patients with PH regarding the benefits of and unsubstantiated arguments against GA in non-cardiac surgery. The literature on risks and benefits of regional anesthesia (RA) in terms of neuraxial, deep plexus, and peripheral nerve block with or without sedation in patients with PH undergoing non-cardiac surgery is reviewed. The choice of anesthesia technique depends on the type of surgery, right ventricle (RV) function, pulmonary artery (PA) pressure, and comorbidities. Given the differences in pathophysiology and mechanical circulatory support (MCS) between the RV and left ventricle (LV), the indications, goals, and contraindications of VA-ECMO as a rescue in cardiopulmonary arrest and pulmonary hypertensive crisis in patients with PH are discussed. Given the significant morbidity and mortality associated with PH, multidisciplinary teams including anesthesiologists, surgeons, cardiologists, pulmonologists, and psychological and social worker support should provide perioperative management.
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Tsukinaga A, Yoshitani K, Kubota Y, Kanemaru E, Nishimura K, Ogata S, Nakai M, Tsukinaga R, Kamiya CA, Yoshimatsu J, Ohnishi Y. Anesthesia for Cesarean Section and Postpartum Cardiovascular Events in Congenital Heart Disease: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2020; 35:2108-2114. [PMID: 33309496 DOI: 10.1053/j.jvca.2020.11.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/09/2020] [Accepted: 11/18/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To clarify the association between anesthetic technique and maternal and neonatal outcomes in parturients with congenital heart disease (CHD). DESIGN Retrospective, observational cohort study. SETTING An academic hospital. PARTICIPANTS A total of 263 consecutive parturients with CHD who underwent cesarean section from 1994 to 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The authors compared postpartum cardiovascular events (composite of heart failure, pulmonary hypertension, arrhythmia, and thromboembolic complications) and neonatal outcomes (intubation and Apgar score <7 at one or five minutes) by anesthetic technique. Among 263 cesarean sections, general anesthesia was performed in 47 (17.9%) parturients and neuraxial anesthesia in 214 (81.3%) parturients. Cardiovascular events were more common in the general anesthesia group (n = 7; 14.9%) than in the neuraxial anesthesia group (n = 17; 7.9%). Generalized linear mixed models assuming a binomial distribution (ie, mixed-effects logistic regression), with a random intercept for each modified World Health Organization classification for maternal cardiovascular risk, revealed that general anesthesia was not significantly associated with cardiovascular events (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.30-3.29). In addition, general anesthesia was associated with composite neonatal outcomes (Apgar score <7 at one or five minutes or need for neonatal intubation; OR, 13.3; 95% CI, 5.52-32.0). CONCLUSION Anesthetic technique is not significantly associated with postpartum composite cardiovascular events. General anesthesia is significantly associated with increased need for neonatal intubation and lower Apgar scores.
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Affiliation(s)
- Akito Tsukinaga
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenji Yoshitani
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Yosuke Kubota
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Eiki Kanemaru
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Michikazu Nakai
- Department of Statistical Analysis, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Rie Tsukinaga
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Chizuko A Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Jun Yoshimatsu
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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6
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Kim YS, Kim HS, Jeong H, Lee CH, Lee MK, Choi SS. Efficacy of electrical stimulation on epidural anesthesia for cesarean section: a randomized controlled trial. BMC Anesthesiol 2020; 20:146. [PMID: 32522156 PMCID: PMC7285553 DOI: 10.1186/s12871-020-01063-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/01/2020] [Indexed: 11/26/2022] Open
Abstract
Background Loss of resistance (LOR) technique is a widely used method to identify the epidural space. However, cases of inadequate epidural anesthesia in cesarean section were frequently reported. Also, the success rate of epidural anesthesia with LOR technique varied depending on the proficiency of the practitioner. The purpose of this study was to assess the efficacy and safety of electrical stimulation to identify epidural spaces in cesarean section for novices or clinicians with recent gap in experience. Methods Pregnant women scheduled for elective cesarean section were randomly allocated to two groups. Groups were classified based on the methods used for identifying the epidural space: the LOR group (group L) and the LOR with epidural electrical stimulation group (group E). Clinicians with less than 10 epidural cesarean section experiences in the recent year performed epidural anesthesia for cesarean section. In the group E, a RegionalStim® conductive catheter was inserted through the Tuohy needle, and the guidewire passing through the catheter was connected to a peripheral nerve stimulator. The intensity of the stimulation was gradually increased from 0.25 mA to 1.5 mA until paresthesia was elicited and radiated. We assessed the success of epidural anesthesia (complete success, partial success or failure). Other clinical parameters including maternal satisfaction, time required for epidural anesthesia, neonatal Apgar scores, pain scores and adverse events were compared between the two groups. Results Except for 6 patients who withdrew consent, 54 patients were enrolled in this study (28 for the group L and 26 for the group E). The demographic data showed no difference between the two groups. There was no adverse event resulted from electrical stimulation. The group E showed higher rate of complete success, sensitivity in finding epidural space and maternal satisfaction compared to the group L (21/26 vs. 15/28, p = 0.034, 0.96 vs. 0.68, p = 0.012 and 4.04 vs. 3.39, p = 0.02, respectively). The other clinical parameters showed no differences between the two groups. Conclusion In addition to the conventional LOR technique, identifying epidural spaces using electrical stimulation led to better outcomes without additional risks for novices as well as clinicians with recent gap in experience. Trial registration This study was retrospectively registered in the ClinicalTrials.gov Registry (NCT03443466) on February 23, 2018.
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Affiliation(s)
- Young Sung Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Hyo Sung Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Hyerim Jeong
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Chung Hun Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Mi Kyoung Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Sang Sik Choi
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea.
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7
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When Your 35-Year-Old Patient has a Sternotomy Scar: Anesthesia for Adult Patients with Congenital Heart Disease Presenting for Noncardiac Surgery. Int Anesthesiol Clin 2019; 56:3-20. [PMID: 30204603 DOI: 10.1097/aia.0000000000000204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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8
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9
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10
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Dhir S, Racine J, Gratton R, Bergin L, de Vrijer B. Management of labour and delivery in congenitally corrected transposition of great arteries. Acta Anaesthesiol Scand 2015; 59:1397-403. [PMID: 26176905 DOI: 10.1111/aas.12583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 03/18/2015] [Accepted: 05/24/2015] [Indexed: 01/04/2023]
Abstract
A descriptive case report of the labour and delivery management of a 28-year-old woman who presented with congenitally corrected transposition of great arteries, dextrocardia, systemic ventricular dysfunction and junctional tachycardia. Patients with congenitally corrected transposition have a thin-walled morphological right ventricle as the systemic circulatory pump. The stress of increased cardiac output can lead to congestive heart failure, systemic atrioventricular valve regurgitation and arrhythmias. We used minimally invasive continuous cardiac output monitoring, fluid balance optimization and good maternal pain control to prevent decompensation and achieve vaginal delivery with a good maternal and neonatal outcome.
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Affiliation(s)
- S. Dhir
- Department of Anesthesiology and Perioperative Medicine; Western University; London Ontario Canada
| | - J. Racine
- Department of Anesthesiology and Perioperative Medicine; Western University; London Ontario Canada
| | - R. Gratton
- Department of Obstetrics and Gynaecology; Division of Maternal Fetal Medicine; Western University; London Ontario Canada
| | - L. Bergin
- Department of Cardiology; Western University; London Ontario Canada
| | - B. de Vrijer
- Department of Obstetrics and Gynaecology; Division of Maternal Fetal Medicine; Western University; London Ontario Canada
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11
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Warrick CM, Hart JE, Lynch AM, Hawkins JA, Bucklin BA. Prevalence and descriptive analysis of congenital heart disease in parturients: obstetric, neonatal, and anesthetic outcomes. J Clin Anesth 2015; 27:492-8. [DOI: 10.1016/j.jclinane.2015.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 03/18/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
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12
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Tiouririne M, de Souza DG, Beers KT, Yemen TA. Anesthetic Management of Parturients With a Fontan Circulation. Semin Cardiothorac Vasc Anesth 2015; 19:203-9. [DOI: 10.1177/1089253214566887] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Parturients with Fontan physiology provide unique and complex challenges to anesthesiologists. Such challenges include the maintenance of a perfect balance between preload, pulmonary vascular resistance, afterload, and cardiac output in a setting of a single ventricle physiology. The physiological changes of pregnancy add additional burden to an already “fragile” physiology, making the anesthetic management for labor and/or cesarean delivery even more complex. Understanding the impact of these changes on the Fontan physiology and the effect of anesthetic choices on this dyad (pregnancy–Fontan) is an imperative prior to caring for these patients. In an effort to determine how these patients are best managed for labor and/or cesarean delivery, we have reviewed the literature examining the peripartum anesthetic management of parturients with Fontan circulation and have identified 27 case reports.
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Maxwell BG, Eberhardt KJ. Anesthetic and perioperative care of high-risk adults with congenital heart disease: Managing ventricular dysfunction and minimal reserve. PROGRESS IN PEDIATRIC CARDIOLOGY 2014. [DOI: 10.1016/j.ppedcard.2014.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
Adults with congenital heart disease now form the largest group of women with cardiac disease becoming pregnant in the developed world. This is both a mark of impressive steps forward in the management of congenital heart disease and also a challenge to the medical community to develop systems of care that will best serve these women and their babies. Each woman with congenital heart disease presents a unique pattern of challenges for the cardiologist, obstetrician, and anesthesiologist, and their care should be tailored to deal with their individual circumstances. As this population of patients continues to grow, we must continue to learn and improve our diagnostic tools and management strategies to refine their care. This review intends to focus on reviewing the outcomes in this set of patients and also an approach to the assessment and the management of these patients, primarily for an audience of obstetricians, pediatricians, and anesthesiologists.
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Affiliation(s)
- Shaline Rao
- Division of Cardiology, Columbia University Medical Center, New York, NY
| | - Jonathan N Ginns
- Division of Cardiology, Columbia University Medical Center, New York, NY.
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15
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Maxwell BG, Posner KL, Wong JK, Oakes DA, Kelly NE, Domino KB, Ramamoorthy C. Factors Contributing to Adverse Perioperative Events in Adults with Congenital Heart Disease: A Structured Analysis of Cases from the Closed Claims Project. CONGENIT HEART DIS 2014; 10:21-9. [DOI: 10.1111/chd.12188] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Bryan G. Maxwell
- Department of Anesthesiology and Critical Care Medicine; Johns Hopkins University School of Medicine; Baltimore Md USA
| | - Karen L. Posner
- Department of Anesthesiology and Pain Medicine; University of Washington; Seattle Wash USA
| | - Jim K. Wong
- Department of Anesthesia; Stanford University School of Medicine; Stanford Calif USA
| | - Daryl A. Oakes
- Department of Anesthesia; Stanford University School of Medicine; Stanford Calif USA
| | - Nate E. Kelly
- Department of Anesthesia; Stanford University School of Medicine; Stanford Calif USA
| | - Karen B. Domino
- Department of Anesthesiology and Pain Medicine; University of Washington; Seattle Wash USA
| | - Chandra Ramamoorthy
- Department of Anesthesia; Stanford University School of Medicine; Stanford Calif USA
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Abstract
Congenital cardiac anesthesiology is a young and rapidly growing subspecialty. It embraces a large spectrum of congenital and acquired heart diseases, which now affect the entire life span of patients from “cradle to grave.” One of the challenges faced by congenital cardiac anesthesiologists is reading the large amount of relevant literature from the fields of cardiology, cardiac surgery, intensive care medicine, and anesthesiology. This review highlights some of the current themes in the literature during the past year.
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Affiliation(s)
- Richard J. Ing
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado Denver, Aurora, CO, USA
| | - Mark D. Twite
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado Denver, Aurora, CO, USA
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17
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Perioperative Outcomes of Major Noncardiac Surgery in Adults with Congenital Heart Disease. Anesthesiology 2013; 119:762-9. [DOI: 10.1097/aln.0b013e3182a56de3] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background:
An increasing number of patients with congenital heart disease are surviving to adulthood. Consensus guidelines and expert opinion suggest that noncardiac surgery is a high-risk event, but few data describe perioperative outcomes in this population.
Methods:
By using the Nationwide Inpatient Sample database (years 2002 through 2009), the authors compared patients with adult congenital heart disease (ACHD) who underwent noncardiac surgery with a non-ACHD comparison cohort matched on age, sex, race, year, elective or urgent or emergency procedure, van Walraven comborbidity score, and primary procedure code. Mortality and morbidity were compared between the two cohorts.
Results:
A study cohort consisting of 10,004 ACHD patients was compared with a matched comparison cohort of 37,581 patients. Inpatient mortality was greater in the ACHD cohort (407 of 10,004 [4.1%] vs. 1,355 of 37,581 [3.6%]; unadjusted odds ratio, 1.13; P = 0.031; adjusted odds ratio, 1.29; P < 0.001). The composite endpoint of perioperative morbidity was also more commonly observed in the ACHD cohort (2,145 of 10.004 [21.4%] vs. 6,003 of 37,581 [16.0%]; odds ratio, 1.44; P < 0.001). ACHD patients comprised an increasing proportion of all noncardiac surgical admissions over the study period (P value for trend is <0.001), and noncardiac surgery represented an increasing proportion of all ACHD admissions (P value for trend is <0.001).
Conclusions:
Compared with a matched control cohort, ACHD patients undergoing noncardiac surgery experienced increased perioperative morbidity and mortality. Within the limitations of a retrospective analysis of a large administrative dataset, this finding demonstrates that this is a vulnerable population and suggests that better efforts are needed to understand and improve the perioperative care they receive.
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