2024 FSA Podium and Poster Abstracts

P037: SITUS INVERSUS AND PREGNANCY: USE OF TEE AND ECMO AS A RESCUE TREATMENT STATUS POST CARDIAC ARREST
Arden Woods; Michael Hsu, MD; Erick Rodriguez, MD; Selina Patel, MD; Gregory Geubelle, MD; University of Miami/Jackson Memorial Hospital

Introduction/Background: Dextrocardia and situs inversus are rare conditions that affect approximately 1 in 12000 individuals, often incidentally recognized on chest x-ray or echocardiogram in otherwise asymptomatic individuals. While the conditions are generally harmless, they can be associated with other cardiac malformations, including atrial septal defects, univentricular heart, transposition of the great arteries, and anomalous pulmonary venous return. They can also be associated with conduction abnormalities, including non-malignant arrhythmias like sinus tachycardia and stable supraventricular tachycardias, as well as malignant arrhythmias like high degree AV blocks.

Methods: We present a parturient G5P4004 at 39 weeks with incidental dextrocardia/situs inversus who presented to the hospital for induction of labor after scant prenatal care and recent immigration. While hospitalized, non-reassuring fetal variable decelerations were noted. Prior to cesarean section, the patient developed a narrow complex tachycardia (HR 170s) with associated hypotension. Shortly after, the patient reported chest pain and grabbed her chest. The patient was cardioverted from unstable SVT to sinus tachycardia; however, within 30 seconds, the patient progressed to complete heart block, then bradycardia and asystolic cardiac arrest. The airway was secured immediately, and ACLS was initiated. The rhythm at this time progressed from monomorphic ventricular tachycardia to ventricular fibrillation. Appropriate cardioversion/defibrillation was delivered, and ROSC was achieved. Subsequent TEE noted findings of dextrocardia, cardiogenic shock with EF of 20-25%, severe MR, septal dyssynchrony consistent with LBBB, and severe lateral, anterolateral, and anterior wall hypokinesis, and large trabeculae consistent with LV non-compaction cardiomyopathy. After multidisciplinary discussion, the decision was made to place the patient on VA ECMO.

Results: On post op day 4 (POD), a TTE was performed with VA ECMO on minimal flows showing an EF of 50-55%, with grossly normal wall motion and trace mitral regurgitation, indicative of a near total recovery from severe cardiogenic shock. On POD 2, the patient was extubated. On POD 4, the patient was decannulated from VA ECMO. On POD 11 the patient was discharged home, with no further complications for mother or baby on outpatient follow-up.

Discussion/Conclusion: Dextrocardia is a rare disease for which there is no routine screening. As such, there is a lack of guidance in the care of a parturient with this specific presentation. In this scenario, cardiac arrest likely resulted due to an intrinsic conduction abnormality exacerbated by the hemodynamic and physical changes associated with pregnancy. Presently, patients presenting to labor and delivery at our institution do not receive routine ECGs, and there is no evidence that this would improve patient outcome on a large scale. On literature review, a prior case report described a parturient with dextrocardia who was diagnosed with complete heart block prenatally, which was successfully treated with a transvenous pacemaker.

Overall, we stress three key points: 1) The importance of preoperative cardiac workup in patients with incidental findings of dextrocardia, 2) the importance of TEE guidance for acute cardiogenic shock, and 3) the interdisciplinary decision to utilize VA ECMO as a rescue method to manage cardiogenic shock.