DP56: FIRST REPORTED TERM REPEAT CESAREAN SECTION IN A HEARTMATE 3 RECIPIENT
Kevin Bennett, MD1; Daniel Lazar, MD2; Angelica Delgado, MD2; Sarah Dunn, MD2
1Memorial Healthcare System; 2Envision Physician Services
Pregnancy with Left Ventricular Assist Devices (LVADs) is rare, with only 12 described cases and only three involving the HeartMate 3 (HM3) [1]. Anticoagulation and acquired von Willebrand syndrome (AvWS) in these patients may limit the use of neuraxial anesthesia, while hemodynamic shifts following delivery place the parturient at high risk for acute right ventricular (RV) failure. Current literature lacks granular, real-time hemodynamic data following delivery, leaving a gap in evidence-based protocols [2-4]. Here we describe the peripartum navigation and repeat C-section of a parturient with a HM3 LVAD.
A 37-year-old G3P1011 (BMI 45) with a HM3 LVAD presented for repeat C-section at 37 weeks. A multidisciplinary team (MFM, OB/Cardiac Anesthesia, Heart Failure, CT Surgery) managed the patient with serial evaluation and an anticoagulation bridging plan. Preoperatively, the patient demonstrated platelet dysfunction (ADP/PFA 121s, EPI/PFA 228s) consistent with AvWS [5]. Following arterial and central line placement, general endotracheal anesthesia (GETA) was induced and a transesophageal echocardiography (TEE) probe was placed to allow continuous monitoring of RV function [6].
The patient's BP dropped to 76/61 mmHg following delivery of a healthy female infant (Apgar 9 and 9). TEE demonstrated maintained RV function with minimal septal shifting, indicating that hypotension resulted from a mismatch between RV accommodation and transient SVR reduction rather than primary RV failure. Milrinone (0.25 mcg/kg/min) and epinephrine were initiated for hemodynamic support. Oxytocin was administered via standard dosing, and hemostasis was achieved with desmopressin and tranexamic acid (QBL = 900 mL). The patient was extubated in the OR and discharged POD 2.
This report describes the first example of a term delivery via repeat C-section in a HeartMate 3 recipient [9,10]. While neuraxial anesthesia is typically preferred in obstetrics, the presence of HM3-associated AvWS, evidenced by our patient's prolonged PFA-100, and the requirement for therapeutic anticoagulation may limit its use [5]. The primary hemodynamic concern in LVAD parturients is the rapid autotransfusion, sudden reduction in SVR, and the high risk for acute RV failure [2-4].
Real-time TEE addressed a significant gap in the literature regarding granular hemodynamic monitoring during the delivery of an LVAD patient [6]. While the patient experienced immediate post-delivery hypotension, TEE confirmed preserved RV contractility and minimal septal shifting. This diagnostic clarity allowed the team to characterize the hypotension as a mismatch between RV accommodation and transient SVR reduction rather than primary RV failure.
To maintain this balance, we avoided bolus oxytocin and began a controlled infusion with sufficient uterine tone [7]. Methylergonovine and carboprost were strictly avoided to prevent acute increases in RV afterload. Our findings suggest that continuous RV monitoring via TEE should be considered to differentiate benign SVR shifts from catastrophic RV failure in this unique population.
1. DOI: 10.4103/aca.aca_102_23
2. DOI: 10.1016/j.healun.2019.04.004
3. DOI: 10.1161/CIRCULATIONAHA.122.063167
4. DOI: 10.1016/j.jacc.2024.08.031
5. DOI: 10.1182/hematology.2019001334
6. DOI: 10.1161/CIRCULATIONAHA.122.063134
7. DOI: 10.3109/00016347809154885
8. DOI: 10.1111/trf.15313
9. DOI: 10.1097/AOG.0b013e3182167761
10. DOI: 10.1016/j.athoracsur.2017.02.046