P037: ANESTHETIC MANAGEMENT FOR EMERGENT CESAREAN DELIVERY IN THE SETTING OF ACUTE INFECTIVE ENDOCARDITIS AND A RIGHT ATRIAL MASS
Ibrahim Ali, MD; Drew S Hicks, DO; Mariana Acosta, MD; Paloma Toledo, MD, MPH; Cosmin Guta, MD
Jackson Health System/University of Miami
Infective endocarditis (IE) during pregnancy is uncommon but associated with significant maternal and fetal risk, especially when complicated by intracardiac masses, sepsis, and right heart strain. Effective management necessitates prompt multidisciplinary collaboration to optimize maternal hemodynamics, determine optimal timing of delivery, manage anticoagulation, and formulate an anesthetic plan, including consideration of extracorporeal membrane oxygenation (ECMO) support.
A 35-year-old G2P0101 at 32 weeks’ gestation with hyperemesis gravidarum requiring total parenteral nutrition presented with Serratia marcescens and Streptococcus oralis bacteremia and a 2.3-cm mobile right atrial (RA) mass. Her medical history was notable for tricuspid valve endocarditis during a previous pregnancy. Therapeutic anticoagulation with heparin was initiated.
Within 24 hours of antibiotic de-escalation, the patient developed sepsis with laboratory evidence of clinical deterioration. Repeat echocardiography revealed interval enlargement of the right atrial mass, which was attached to an indwelling catheter. Due to worsening maternal status and a category II fetal heart rate tracing, maternal–fetal medicine recommended emergent cesarean delivery. Heparin was discontinued immediately, and cardiothoracic surgery was present in the operating room on standby for potential ECMO cannulation and initiation. Intraoperative transesophageal echocardiography (TEE) was utilized to continuously monitor the right atrial mass throughout the procedure. Cesarean delivery under general anesthesia was completed safely within one hour, after which the patient was transferred intubated to the intensive care unit.
Due to the elevated risk of postoperative hemorrhage after cesarean delivery and the anticipated requirement for high-dose intraoperative heparin, AngioVAC thrombectomy of the right atrial mass was deferred for five days. The procedure was subsequently performed without complications, and the patient recovered fully.