2022 FSA Podium and Poster Abstracts

P013: MANAGEMENT OF AN ACUTE DECOMPENSATED HEART FAILURE OBSTETRIC PATIENT: THE CIRCUITOUS ROUTE
Roshni Patel; Harish Ram; University of Miami

A 33-year-old-female with BMI 44.89 presented at outside hospital for the first time at 29 weeks gestational age (GA) for stomach pain. At that time her heart rate was noted to be 200’s with a baseline at 140-150s. Fetal heart tones was present with no other abnormalities. On a follow-up visit at 37.5 weeks GA she was referred to our hospital for no fetal heart tones. Her heart rate continued to be at 160s bpm. Fetal demise was confirmed by ultrasound. Her past medical history was significant was gestational diabetes and cardiac ablation. Subsequent work-up demonstrated biventricular failure, severe mitral and tricuspid regurgitation (Figure 1).

The decision was made to place an IABP, subsequent C-section with ECMO standby. Of note left common femoral DVT noted. After induction of anesthesia patient was hemodynamically stable but was persistently hypoxemic requiring emergent VA-ECMO. 4 L flow was easily achieved, and oxygenation improved. Right ventricle appeared decompressed with left ventricular ejection fraction mildly improved from baseline of 10% to 15% to 20%. Cesarean section proceeded. During C-section left groin hematoma and retroperitoneal hematoma noted. Patient was noted to be in hemorrhagic shock requiring massive transfusion protocol. Subsequent intraoperative course was complicated with abdominal compartment syndrome with concern for harlequin syndrome, and tachycardia continued to persist that seemed unresponsive to adenosine, amiodarone and cardioversion (Figure 2). She was transferred to intensive care unit on ECMO but requiring no other vasoactive substances.

Perioperative decision making involving extracorporeal circuit in an obstetric patient who presented in acute decompensated heart failure will be presented. The role of bedside imaging, extracorporeal circuit weaning strategies and the tortuous post-operative course will be discussed.