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Cesarean section in a patient with familial cardiomyopathy and a cardioverter-defibrillator

[Une césarienne chez une patiente atteinte de cardiomyopathie familiale et porteuse d’un défibrillateur à synchronisation automatique]

Don A. Frost, MD^* and James A. Dolak, MD PhD

^* From the Department of Anesthesiology, St. Vincent’s Infirmary-Doctor’s Hospital, Little Rock, Arkansas; and the
Department of General Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Address correspondence to: Dr. James A. Dolak, Department of General Anesthesiology, The Cleveland Clinic Foundation, 9500 Euclid Avenue, E-31, Cleveland, Ohio 44195, USA. Phone: 216-444-0224; Fax: 216-444-2294; E-mail: dolakj{at}ccf.org

Purpose: To describe the impact of maternal automatic implantable cardioverter-defibrillator (AICD) therapy on pregnancy outcome, and discuss the clinical rationale for regional anesthesia in parturients with AICDs.

Clinical features: A 20-yr-old primigravida with a history of familial cardiomyopathy and AICD placement presented at 39 weeks gestational age for elective labour induction. Ultimately, the patient underwent a Cesarean section for a failed induction. Her AICD was deactivated during the peripartum period, although the pacing function remained active as she had an underlying heart rhythm of less than 34 beat·min^–1. The patient had continuous electrocardiogram monitoring via an external defibrillating unit to which she remained connected by external defibrillator pads. Labour analgesia and surgical anesthesia were provided with a lumbar epidural dosed with varying concentrations of bupivacaine. This management resulted in an excellent maternal and fetal outcome.

Conclusions: Automatic implantable cardioverter-defibrillators are being utilized more frequently in the obstetric population, and appear compatible with good fetal outcomes. Experience with the anesthetic management of these patients is markedly limited – primarily involving reports of general anesthesia for Cesarean section. Epidural anesthesia, however, offers distinct advantages in this patient population including easy conversion from labour analgesia to surgical anesthesia, preservation of fetal-maternal hemodynamics, prevention of increases in plasma catecholamines due to labour or operative pain, and, finally, possible direct suppression of arrhythmias by pharmacologically-active plasma levels of local anesthetic.

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