Anesthetic Challenges in Management of Parturient With Congenitally Corrected Transposition of Great Arteries
Congenitally corrected transposition of the great arteries is once in a blue moon heart defect in which the heart’s lower two chambers and ventricles, are reversed in their positions. Right ventricle (RV) battles to function as the ventricular pump against the substantial systemic vascular resistance. As the age increases, these parturient tend to develop primitive ventricular dysfunction. CCTGA has a prevalence of 0.4–0.6% of all congenital heart disease cases and complete heart block develops in cases of 30% CCTGA. In these parturients the physiological cardiovascular changes of pregnancy may expedite the rate of ventricular failure. We describe anesthetic challenges in management of parturient with CCTGA associated with hypothyroidism and complete heart block posted for elective caesarean section.
32 year old antenatally unregistered primigravida with 37 weeks of gestation, body mass index 19.2kg/m2 known case of hypothyroidism on Tab. Eltroxin 25 microgram OD, came to emergency room with complaints of chest pain and shortness of breath [NYHA grade 3].Diuretics and bronchodilators therapy was given for symptomatic relief. Two dimensional (2D) echocardiography showed Ejection fraction of 45% with congenitally corrected transposition of great arteries, severe RV dysfunction, moderate pulmonary artery hypertension( Pulmonary artery pressure of 42 mmHg) and severe AV valve regurgitation.
Cardiologist consultation was taken; they advised elective caesarean section and corrective surgery with permanent pacemaker insertion after one month of delivery and temporary pacing in case of unstable hemodynamics during caesarean section. Thorough pre anesthetic evaluation done, On examination , Heart rate 42beats/min irregular, low volume, No radio-radial, radio-femoral delay, Blood pressure 100/70mmHg, Respiratory rate 20/min, Saturation on room air 94% .On auscultation a systolic murmur was heard on left of sternum with basal crepitations. Airway and spine examination normal. Laboratory parameters suggestive of: Hemoglobin 11.2gm/dl, platelet count 188000/uL, White blood cell 11,000/Ul, Prothrombin time 14.6sec, INR 1.1, Liver and renal function tests were within normal limits. Thyroid function test showing T3 -2.55 (1.5-4.1)pg/ml, T4-0.87( 0.8-1.4)ng/dl and TSH -9.3(0.3-5.5).
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