Key result
In a 22-year-old female with severe scoliosis and Marfan syndrome, high thoracic epidural anesthesia combined with general anesthesia allowed for extubation 12 hours after mitral valve replacement.
Why the study?
Thoracic epidural anesthesia improves analgesia and outcomes in high-risk cardiac surgical patients, but its role in patients with severe scoliosis undergoing cardiac surgery required reporting.
Case Report (n=1)
High thoracic epidural anesthesia can be safely used as an adjunct to general anesthesia for cardiac surgery in high-risk patients with severe scoliosis and restrictive lung disease to facilitate postoperative recovery.
Hypothesis-generating for epidural adjuncts in high-risk cardiac cases; leaves open need for prospective validation before practice consideration.
Thoracic epidural anesthesia (TEA) has been used in high-risk cardiac surgical patients as an adjunct to general anesthesia.[ 1 ] Epidural anesthesia has improved analgesia and outcomes after cardiac surgery.[ 2 ] We report here a case of severe scoliosis who underwent mitral valve replacement under general anesthesia plus high TEA. A 22-year-young female, a known case of Marfan syndrome came to us with severe mitral regurgitation due to mitral valve prolapse for mitral valve replacement. Her height and weight was 172 cm and 35 kg, respectively. Preoperative examination revealed she had a severe scoliosis with convexity toward right side ([ Fig. 1 ]). Her pulmonary function test showed severe restrictive lung disease with forced expiratory volume in 1 second (FEV1) which was 1.43 L (43% predicted) and FEV1/FVC% (forced vital capacity percent) was normal. Fig. 1 Chest X-ray showing severe scoliosis. In view of her poor pulmonary status, a thoracic epidural catheter was placed at the level of T1-T2 by hanging drop technique night before surgery. The next day she underwent mitral valve replacement with a bioprosthetic valve. Postoperatively she was kept on epidural ropivacaine 0.375% infusion at 6 mL/h. She was extubated 12 hours after surgery. The epidural catheter was removed on third postoperative day. Median sternotomy for cardiac surgery causes uncoordinated chest expansion and weakness of respiratory muscles. Patients with underlying respiratory problems are at increased risk of pulmonary complications postoperatively. Hyperreactive airway, postoperative pain, immobilization after surgery, and sedative analgesics compound the problem. Mehta et al has shown that TEA might decrease pulmonary, cardiovascular and renal complications, provide better analgesia without sedation, and allows early extubation in high-risk cardiac surgical patients.[ 1 ] [ 3 ] Analgesia without sedation helps in rapid mobilization of the patients and active pulmonary rehabilitation after surgery. Hemmerling et al also demonstrated earlier extubation and oxygen withdrawal time with high TEA.[ 4 ] Publication History Publication Date: 20 March 2020 (online)
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Mehta et al. (2019) conducted a case report in Severe mitral regurgitation and severe scoliosis in Marfan syndrome (n=1). Thoracic epidural anesthesia (TEA) plus general anesthesia was evaluated on Postoperative recovery and extubation time. In a 22-year-old female with severe scoliosis and Marfan syndrome, high thoracic epidural anesthesia combined with general anesthesia allowed for extubation 12 hours after mitral valve replacement.
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