A 25 y/o pregnant woman A 25 y/o pregnant woman with acute heart failurewith acute heart failure

RiRi 曾渥然曾渥然 /Ri/Ri 楊智勝楊智勝 /CR/CR康庭瑞康庭瑞 /VS/VS鄭鄭淳心淳心

Brief HistoryBrief History

25 y/o female patient25 y/o female patient GA 35GA 35++ weeks with twin pregnan weeks with twin pregnan

cycy BL: 155 cmBL: 155 cm BW: 47/62 kgBW: 47/62 kg Past history: deniedPast history: denied

OB/GYN historyOB/GYN history G2P0AA1G2P0AA1 LMP: 94.4.9LMP: 94.4.9 EDC: 95.1.16EDC: 95.1.16 Prenatal conditionPrenatal condition

GDM: negativeGDM: negative VDRL: non-reactiveVDRL: non-reactive HIV: negativeHIV: negative Blood type: B, Rh(+)Blood type: B, Rh(+) SMN carrier (-)SMN carrier (-)

Prenatal examinationPrenatal examination

94.11.14 (3194.11.14 (31+2+2 wks) wks) Urine sugar(-), Urine protein(-)Urine sugar(-), Urine protein(-) 59kg, 91/83 mmHg59kg, 91/83 mmHg

94.11.30 (3394.11.30 (33+5+5 wks) wks) 62kg, 121/97 mmHg62kg, 121/97 mmHg Urine sugar(-), Urine protein(2Urine sugar(-), Urine protein(2++))

94.12.14 ( 3594.12.14 ( 35+5+5 wks) wks) 66kg, 130/95 mmHg66kg, 130/95 mmHg Urine sugar(-), Urine protein(4Urine sugar(-), Urine protein(4++))

Clinical symptoms and signsClinical symptoms and signs

Exersional dyspnea for one weekExersional dyspnea for one week OrthopneaOrthopnea Vital signsVital signs

36.5/129/20, BP:135/108mmHg36.5/129/20, BP:135/108mmHg PEPE

Neck: JVE(+)Neck: JVE(+) Chest: bilateral basal cracklesChest: bilateral basal crackles Heart: RHB with systolic murmurHeart: RHB with systolic murmur Abd: ovoid, normactive BoSAbd: ovoid, normactive BoS Ext: edema (+)Ext: edema (+)

Cardiac Echo (12.14)Cardiac Echo (12.14)

Moderate to severe MRModerate to severe MR Moderate PR & TRModerate PR & TR LVEF: 43%LVEF: 43% LV dilatation (47mm)LV dilatation (47mm) Pulmonary hypertensionPulmonary hypertension

PG = 50mmHgPG = 50mmHg Small amount pericardial Small amount pericardial

effusioneffusion

12.14, 12.14, pre-C/Spre-C/S

Lab DataLab Data

CBCCBC WBCWBC

K/μL K/μL

RBCRBC

M/μLM/μL

HBHB

g/dLg/dL

HCTHCT

%%

MCVMCV

fLfL

PLTPLT

K/μL K/μL

941214941214 8.118.11 4.034.03 10.910.9 31.831.8 78.978.9 312.0312.0

BCSBCS T-bilT-bil

mg/dL mg/dL

D-bilD-bil

mg/dLmg/dL

ASTAST

U/LU/L

ALTALT

U/LU/L

941214941214 0.540.54 0.10.1 3232 1515

BCSBCS NaNa

mmol/Lmmol/L

KK

mmol/Lmmol/L

941214941214 133133 4.74.7

UNUN

mg/dL mg/dL

CRECRE

mg/dLmg/dL

19.519.5 0.80.8

PTPT PTTPTT

941214941214 10.810.8 28.328.3

ImpressionImpression

Twin pregnancy at 35Twin pregnancy at 35thth week s/p week s/p emergent Cesarean sectionemergent Cesarean section

PreeclampsiaPreeclampsia Maternal heart failure, suspecteMaternal heart failure, suspecte

d cardiomyopathyd cardiomyopathy

Anaesthesia RecordsAnaesthesia Records

Arterial lineArterial line Induction agentsInduction agents

AtropineAtropine EtomidateEtomidate SuccinylcholineSuccinylcholine

Under ETGA (6:50PM)Under ETGA (6:50PM) Inhalation of isofluraneInhalation of isoflurane Cis-atracurium for m. relaxantCis-atracurium for m. relaxant Midazolam for sedationMidazolam for sedation Fentanyl for pain controlFentanyl for pain control Central venous catheterCentral venous catheter

Delivery time: 7:03PMDelivery time: 7:03PM Twin A (vertex extraction)Twin A (vertex extraction)

BBW:2016gmBBW:2016gm Apgar score: Apgar score: 5 5 8 8 Fetal anomaly: nilFetal anomaly: nil

Twin B (breech extraction)Twin B (breech extraction) BBW:2344gmBBW:2344gm Apgar score: Apgar score: 5 5 8 8 Fetal anomaly: nilFetal anomaly: nil

Placenta: intactPlacenta: intact EBL: 500mlEBL: 500ml

4FI treatment course(II)4FI treatment course(II)

MedicationMedication Albumin 2btls IV x 3 daysAlbumin 2btls IV x 3 days Lasix: 1 amp TIDLasix: 1 amp TID Perdipine titrationPerdipine titration MgSO4 in D5WMgSO4 in D5W Inderal(10) 1tab BIDInderal(10) 1tab BID

Ventilator settingsVentilator settings Mode: SIMV + PSMode: SIMV + PS FiO2:35%FiO2:35% PS/PEEP:8/4PS/PEEP:8/4 SpO2:96%SpO2:96%

Extubation at 12.16_10:45AMExtubation at 12.16_10:45AM

12/14 Send to 4 FI12/14 Send to 4 FI 12/16 ETT was removed12/16 ETT was removed 12/17 Transfer to general ward 12/17 Transfer to general ward 12/21 Discharge12/21 Discharge

Followed up cardiac echoFollowed up cardiac echo

12/1612/16 LVEF:62%LVEF:62% LVEDD:49mmLVEDD:49mm Moderate MRModerate MR TR, PG:44mmHgTR, PG:44mmHg

12/2012/20 LVEF:48%LVEF:48% LVEDD:55mmLVEDD:55mm Moderate to severe MRModerate to severe MR TR, PG:36mmHgTR, PG:36mmHg

DiscussionDiscussion

Maternal hemodynamic change Maternal hemodynamic change during pregnancyduring pregnancy

Recognition and management of Recognition and management of peripartum cardiomyoparthyperipartum cardiomyoparthy

Maternal hemodynamic changMaternal hemodynamic change during pregnancye during pregnancy

HeartHeart Cardiac outputCardiac output MAP and SVRMAP and SVR Venous returnVenous return Hemodynamic assessmentHemodynamic assessment

HeartHeart

Displacement of diaphragmDisplacement of diaphragm

- left and upward- left and upward

- apex is moved laterally- apex is moved laterally Expand of blood volumeExpand of blood volume

- LVEDD increase- LVEDD increase

- LA/RA diameter increase- LA/RA diameter increase

Cardiac output (CO=SV x HR)Cardiac output (CO=SV x HR)

Cardiac outputCardiac output

PositionPosition

- Increased: left lateral- Increased: left lateral

- Decreased: sitting, supine- Decreased: sitting, supine

MAP and SVRMAP and SVR

MAP and SVRMAP and SVR

Decreased SVRDecreased SVR

- Elevated progesterone level- Elevated progesterone level

- NO, prostaglandin, ANP- NO, prostaglandin, ANP Refractory to hypertensive effectRefractory to hypertensive effect

s of angiotensin IIs of angiotensin II

Venous pressureVenous pressure

Elevated in lower extremitiesElevated in lower extremities EdemaEdema Varicose veinsVaricose veins Deep vein thrombosisDeep vein thrombosis

Hemodynamic assessmentHemodynamic assessment

By arterial lines and Swan-Ganz catheterizationBy arterial lines and Swan-Ganz catheterization

Effect of labor and Effect of labor and immediate puerperiumimmediate puerperium

Elevated MAP and COElevated MAP and CO

- uterine contraction- uterine contraction

- pain and apprehension- pain and apprehension

- position- position

Diagnosis and evaluation of Diagnosis and evaluation of cardiac disease in pregnancycardiac disease in pregnancy

Detailed historical informationDetailed historical information

Physical examination:Physical examination:

murmur( grade 3/6) or radiate to ≧murmur( grade 3/6) or radiate to ≧

carotidcarotid→ pathologic→ pathologic

JVE, peripheral cyanosis, JVE, peripheral cyanosis,

clubbing, pulmonary crackleclubbing, pulmonary crackle

EchocardiographyEchocardiography

The possible etiology of heart The possible etiology of heart failure in this patientfailure in this patient

Previously undiagnosed congenital oPreviously undiagnosed congenital o

r rheumatic diseaser rheumatic disease

Embolic disease or ischemic heart diEmbolic disease or ischemic heart di

seasesease

CardiomyopathyCardiomyopathy

Previously undiagnosed valvular disePreviously undiagnosed valvular dise

asease

Recognition and management of Recognition and management of peripartum cardiomyoparthyperipartum cardiomyoparthy

Maternal death due to cardiac Maternal death due to cardiac diseasedisease

Br J Anaesth 2004;93, 428-39Br J Anaesth 2004;93, 428-39

Peripartum cardiomyopathyPeripartum cardiomyopathy

Incidence: 1:1500~1: 4000Incidence: 1:1500~1: 4000

It is associated with It is associated with older older

maternal age, greater parity, maternal age, greater parity,

black race and multiple black race and multiple

gestation…gestation…

The etiology remains unclear. The etiology remains unclear.

Clinical definition of peripartum caClinical definition of peripartum cardiomyopathyrdiomyopathy

Heart failure within Heart failure within last month of pregnancy last month of pregnancy

or five months postpartumor five months postpartum

Absence of prior heart diseaseAbsence of prior heart disease

No determinable causeNo determinable cause

Strict echocardiographic indication of LV dyStrict echocardiographic indication of LV dy

sfunctionsfunction Ejection fraction < 45%Ejection fraction < 45%

And/orAnd/or

Fraction shortening < 30 %Fraction shortening < 30 %

End-diastolic dimension >2.7 cm per mEnd-diastolic dimension >2.7 cm per m2 2 BSA BSA

The recognition of peripartum The recognition of peripartum cardiomyopathycardiomyopathy

The diagnosis as a challengeThe diagnosis as a challenge S/S that should raise the suspicion of S/S that should raise the suspicion of

HF, including HF, including paroxysmal nocturnal dyspnea, chparoxysmal nocturnal dyspnea, ch

est pain, new regurgitant murmur, pulmonary crackles, est pain, new regurgitant murmur, pulmonary crackles,

JVE, hepatomegalyJVE, hepatomegaly…… EKG: usually NSR or sinus tachycardiaEKG: usually NSR or sinus tachycardia

A high index of suspicion and low threA high index of suspicion and low thre

shold of cardiac echoshold of cardiac echo

Treatment of peripartum cardioTreatment of peripartum cardiomyopathymyopathy Salt restriction and the use of diureticSalt restriction and the use of diuretic

ss If systolic dysfunction, the use of vasIf systolic dysfunction, the use of vas

odilators to reduce afterloadodilators to reduce afterload ACEIACEI→ teratogenicity, neonatal anuric renal failure → teratogenicity, neonatal anuric renal failure (co(co

ntraindicated)ntraindicated) Hydralazine: the drug of choice prepartumHydralazine: the drug of choice prepartum

Atrial arrhythmias should be treated Atrial arrhythmias should be treated with with digoxin.digoxin. Class 3(amiodarone) and class 4(verapamil) ageClass 3(amiodarone) and class 4(verapamil) age

nts have side effects: fetal hypothyroidism, premnts have side effects: fetal hypothyroidism, premature delivery, fetal bradycardia… ature delivery, fetal bradycardia…

Treatment of peripartum cardiTreatment of peripartum cardiomyopathy (Cont.) omyopathy (Cont.)

Patient with poor cardiac output Patient with poor cardiac output (LVEF<35%)(LVEF<35%) Anticoagulation is indicated for the risk oAnticoagulation is indicated for the risk o

f thromboembolism. f thromboembolism. Unfractionated or LMW heparin are the Unfractionated or LMW heparin are the

choice during pregnancy.choice during pregnancy.

The use of The use of ββ- blocker- blocker Carvedilol for dilative cardiomyopathyCarvedilol for dilative cardiomyopathy The application in peripartum cardiomyoThe application in peripartum cardiomyo

pathy is unclear.pathy is unclear.

Cardiomyopathy during pregnCardiomyopathy during pregnancyancy

Delivery of the fetus Delivery of the fetus ↓ ↓ the hemothe hemo

dynamic stress on the heart.dynamic stress on the heart.

The mode of deliveryThe mode of delivery Based on Based on obstetric indicationobstetric indication

Effective pain management is nEffective pain management is n

ecessary.ecessary.

Anesthetic consideration in Anesthetic consideration in this patientthis patient

In patients undergoing GA, the pIn patients undergoing GA, the principles are as for any patient wrinciples are as for any patient with cardiac failure.ith cardiac failure. Maintenance of normal to low heart rate Maintenance of normal to low heart rate

to to ↓O↓O22 demand demand Prevention of large swings in BPPrevention of large swings in BP

The hypertensive response to inThe hypertensive response to intubation can be obtunded by the tubation can be obtunded by the use of alfentanil. use of alfentanil.

Anesthetic implication for stage-C Anesthetic implication for stage-C heart failureheart failure

Two principal cardiovascular Two principal cardiovascular

events:events: Myocardial depressionMyocardial depression

Peripheral vasodilatationPeripheral vasodilatation

The patients with impaired LV The patients with impaired LV

function are dependent onfunction are dependent on the preload the preload

increased sympathetic toneincreased sympathetic tone

Anesthetic consideration in Anesthetic consideration in this patient (Cont.)this patient (Cont.)

Careful monitoring of fluid balanceCareful monitoring of fluid balance Arterial lineArterial line

CVP lineCVP line

Early critical care referral for unstablEarly critical care referral for unstabl

e patiente patient

Critical patients will require Critical patients will require Swan-GaSwan-Ga

nz monitoring, artificial ventilation annz monitoring, artificial ventilation an

d inotropic supportd inotropic support..

Severe myocardial dysfunctionSevere myocardial dysfunction

The use ofThe use of IABP IABP or a or a left left ventricular assisted deviceventricular assisted device needed as a bridge until needed as a bridge until myocardial recovery or cardiac myocardial recovery or cardiac transplantation is performed. transplantation is performed.

The prognosis of peripartum cThe prognosis of peripartum cardiomyopathyardiomyopathy

The mortality rate: 25~50%The mortality rate: 25~50%

Death due to progressive CHF, Death due to progressive CHF,

arrhythmia, or thromboembolism.arrhythmia, or thromboembolism.

Within 6 months:Within 6 months: Half of patient have resolution of LV dilatHalf of patient have resolution of LV dilat

ion.ion.

If not, 85% will die within the next 4~5 yIf not, 85% will die within the next 4~5 y

earsears..

Thank you for your attention!Thank you for your attention!