|Year : 2016 | Volume
| Issue : 1 | Page : 25-27
Benefit of transesophageal echocardiography monitoring during cesarean section in a patient with complete atrioventricular canal defect
Amarpreet Gill1, Dinesh Garg2, Rajesh Chand Arya2, Sunil Katyal1, Gurpreet Gill2, Sunil Juneja3
1 Department of Anaesthesia and Critical Care, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana, Punjab, India
2 Department of Cardiac Anaesthesia, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana, Punjab, India
3 Department of Obstetrics and Gynecology, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana, Punjab, India
|Date of Web Publication||22-Apr-2016|
Dr. Rajesh Chand Arya
Department of Cardiac Anaesthesia, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana, Punjab
Source of Support: None, Conflict of Interest: None
Anesthesia is a challenge in patients with congenital heart disease, especially during pregnancy and surgical delivery. A 23-year-old with a 34-week gestation, primigravida with atrioventricular (AV) canal defect was scheduled for a cesarean section. Preoperative transthoracic echocardiography (TTE) revealed a complete AV canal defect (Rastelli type II) with left-to-right shunt. Ventricular functions were normal. The patient was administered general anesthesia with endotracheal intubation, and a transesophageal echocardiography (TEE) probe was placed to monitor cardiac functions. The volume status of the parturient and the shunt fraction were continuously monitored with the echocardiography probe during the surgery. Minimal shunting at ventricular septal defect (VSD) was observed, as it was covered by the AV valve leaflets. The patient tolerated the procedure well and the trachea was extubated once she fulfilled the extubation criteria. Intraoperative TEE monitoring was a useful tool to understand and manage hemodynamic variations during cesarean section in the parturient with a complex cardiac lesion.
Keywords: Atrioventricular (AV) canal defect, cesarean section, general anesthesia, lower segment cesarean section (LSCS), transesophageal echocardiography (TEE)
|How to cite this article:|
Gill A, Garg D, Arya RC, Katyal S, Gill G, Juneja S. Benefit of transesophageal echocardiography monitoring during cesarean section in a patient with complete atrioventricular canal defect. J Obstet Anaesth Crit Care 2016;6:25-7
|How to cite this URL:|
Gill A, Garg D, Arya RC, Katyal S, Gill G, Juneja S. Benefit of transesophageal echocardiography monitoring during cesarean section in a patient with complete atrioventricular canal defect. J Obstet Anaesth Crit Care [serial online] 2016 [cited 2019 Sep 23];6:25-7. Available from: http://www.joacc.com/text.asp?2016/6/1/25/181070
| Introduction|| |
Anesthesia is a challenge in patients with complex congenital heart disease and the challenge is greater in pregnant patients scheduled for lower segment cesarean section (LSCS). We present the anesthetic management of a parturient with complete atrioventricular (AV) canal defect. The report demonstrates the advantages of intraoperative transesophageal echocardiography (TEE) monitoring for intraoperative management during LSCS.
| Case Report|| |
A 23-year-old, with a 34-week gestation primigravida was scheduled for LSCS. Her antenatal period was uneventful. Preoperative transthoracic echocardiography (TTE) showed complete AV canal defect (Rastelli type II); a small, 3 mm ventricular septal defect (VSD) with left-to-right shunt; large ostium primum atrial septal defect (ASD); concordant major vessels; normal pulmonary drainage; and severe pulmonary stenosis with post stenotic dilatation. Coarctation of the aorta and patent ductus arteriosus were not present. Ventricular functions were normal. Her weight was 72 kg and airway was Mallampati class I. All blood reports were normal except for a hemoglobin level of 9.0 g%. General anesthesia with endotracheal intubation was planned. The right internal jugular vein and the left radial artery were cannulated for invasive hemodynamic monitoring before the induction of anesthesia. The baseline heart rate was 96/min and the blood pressure was 106/70 mmHg. Anesthesia was induced with Propofol and trachea intubated, using rapid sequence intubation technique, using succinylcholine. Anesthesia was maintained with oxygen, air/nitrous oxide, and isoflurane (0.5%). Once the baby was delivered, neuromuscular blockade was achieved with Pancuronium Bromide. After childbirth, 1 mg Midazolam and 100 mcg fentanyl were administered intravenously (IV). 40 IU oxytocin was administered after childbirth/administered as slow IV infusion. TEE probe was placed after tracheal intubation to monitor cardiac functions. Intraoperative TEE confirmed the diagnosis of AV canal defect, however, pulmonary stenosis was not found to be severe. There was minimal shunting across the VSD, as it was covered by AV valve leaflets [Figure 1] and [Figure 2]. The volume status of the cardiac chambers was continuously monitored by TEE by visual assessment and by observing septal movements. Color Doppler was used to monitor the shunt across chambers. Fluids and inotropes/dilator therapy was based on TEE Doppler findings. A total of 800 mL of Ringer's Lactate was administered intraoperative. Dopamine/dilator was used in dose of when cardiac chambers preload was assessed as high. The blood pressures of the patient were maintained between 130 mmHg systolic and 90 mmHg systolic and the heart rate between 72/min and 96/min. There was no episode of desaturation. The airway pressures were maintained at 12-18 cm water (H 2 O). No blood transfusion was needed. On completion of the surgery, TEE probe was removed as well and the trachea extubated once the patient fulfilled the extubation criteria. The patient was shifted to the intensive care unit for monitoring. Both mother and baby were discharged in stable condition with an advice to follow-up with a cardiologist.
|Figure 1: TEE Mid Esophageal four chamber view showing ASD, VSD, and common atrioventricular valve— complete AV canal defect|
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|Figure 2: TEE Mid Esophageal four chamber view (dual 2D and color Doppler) showing left-to-right shunting through AV canal defect (through both ASD and VSD)|
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| Discussion|| |
Patients with congenital heart defects may progress to adult life but as age progresses, the mortality due to these increases.  AV canal defect comprises of ASD, VSD, and common AV valve. Pathophysiology includes left-to-right shunt, increased pulmonary vascular resistance, and pressure [pulmonary artery hypertension (PAH)], that might finally lead to the reversal of flow through the cardiac defect (Eisenmenger Syndrome) and congestive cardiac failure (CCF). Patients may present with cardiomegaly, arrhythmia, or even ischemia. Pregnancy imposes an extra burden on an already compromised cardiorespiratory reserve. Mortality rates for such parturients have been reported as ~0.1-1% in low risk patients, 1-5% in patients with moderate risk, and 5-30% in patients with high risk heart disease. Even in the first 20 weeks of gestation, the parturient may experience significant cardiac problems due to increased cardiac output (40% above normal levels by 20 weeks) and blood volume by 50%.  Clinical outcome depends on the severity of PAH and its reversibility with vasodilators. 
There are reports of successful use of neuraxial anesthesia in such patients. We administered general anesthesia for two reasons. First, as the patient had a complex congenital defect, it would have been easier to manage any complications during surgery as the airway was secure. Second, we wanted to monitor the cardiac status with echocardiography intraoperatively and this would not have been possible if the surgery was carried out in under neuraxial blockade. There was no contraindication to the use of general anesthesia. We used Propofol due to its cardiac stability and as it is a routine protocol in our institute.
In the present case, the diagnosis was made before the surgery was planned and the patient was stable in the antenatal period. There are large hemodynamic changes during pregnancy and more so during delivery due to uterine contractions. The effects of such changes can be monitored with TEE. Our main concern in this patient was to monitor the direction of shunting. As the patient was having left-to-right shunt, her saturation was maintained, but a change in direction of shunting could have changed the oxygen saturations and resulted in an adverse outcome. This shunting might change especially when drugs for uterine contraction, e.g., oxytocin and methergine are given after the delivery of the baby. With TEE, we could monitor this shunting with the help of color Doppler and could guide our therapy accordingly. We could monitor the cardiac chamber volumes and detect CCF early as well. There were no significant changes in hemodynamics intraoperatively. With TEE, we could monitor for embolism or other associated anomalies such as infective endocarditis.
| Conclusion|| |
To conclude, intraoperative TEE monitoring is a useful tool for better understanding and management of hemodynamics in parturients with complex cardiac lesions undergoing cesarean section. However, it is very unlikely that this monitoring can be used under neuraxial block that is the technique of choice in such cases.
Dr. Sunil Juneja, Dr. Gurpreet Singh Gill.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]