Pregnancy with dilated cardiomyopathy—General or regional anesthesia: An anesthesiologist’s dilemma

Sir, Dilated cardiomyopathy (DCM) is a disease characterized by impaired systolic function due to the dilation of either or both ventricles of the heart.[1] These patients may or may not land into heart failure. DCM in pregnancy, though rare, is a great challenge to anesthesiologists.[2,3] Though literature is available on the management of DCM in pregnancy,[4,5] there is always a dilemma in choosing regional and general anesthesia, especially in the parturient with poor contractility. We, hereby, share our experience of successfully managing a pregnant female with DCM (low ejection fraction of 15%) with associated ascites and acute renal injury. A 22-year pregnant female (primigravida 36 weeks 2 days) came for an elective cesarean section. She was diagnosed with dilated cardiomyopathy 2 months back and was started on tablet metoprolol 12.5 mg and furosemide 20 mg per day. She had moderate ascites and mild pericardial effusion for 1 month. Two-dimensional echocardiography showed global hypokinesia with left atrial dilatation, moderate mitral and tricuspid regurgitation, and ejection fraction (EF) of 15%. Her breath-holding time was <15 s. She also had a history of hypothyroidism for 9 months for which she was taking thyroxine 50 mcg. Her recent thyroid stimulating hormone (TSH) was 7.3 mIU/l with normal T3 and T4 hormones. She was also diagnosed with acute kidney injury 2 months back (creatinine 2) with hematuria for the past 3 days. Her recent complete blood count picture was normal with hemoglobin of 11.9 gm/dl and platelet count of 2.29 lacs. The cesarian section was planned under general anesthesia. Preoperative ultrasonography was performed to assess the inferior vena cava (IVC) in the right upper quadrant transhepatic window. IVC was 2.3 cm in diameter and non-collapsible. Thus, this patient was in a fluid overload condition. After written informed consent, the patient was taken to the operation theater. All the American Society of Anesthesiologists monitors were attached. Under local anesthesia, left radial artery cannulation was done for invasive blood pressure monitoring. Central line was inserted in the right internal jugular vein under local anesthesia. Dobutamine and noradrenaline infusions were connected to the central line. The patient was then induced with 50 mcg fentanyl, 20 mg of etomidate, and 80 mg succinylcholine followed by intubation with 7 mm endotracheal tube. The anesthesia was maintained with oxygen:nitrous oxide (40:60), sevoflurane and atracurium (20 mg). After delivery of the baby, fentanyl 100 mcg was given. Fluid management is done with 500 ml crystalloid. The patient remained hemodynamically stable intraoperatively (Blood pressure = 134/83 mmHg, heart rate = 87/min, oxygen saturation 99%, end-tidal CO2 = 34 mmHg) with minimum dobutamine infusion at 5 mg/kg/min. At the end of the surgery, the patient was extubated at shifted to the post-anesthesia care unit. In this case, we choose general anesthesia over regional anesthesia because of the following reasons. First, the patient had DCM with global hypokinesia, with a very low EF of 15%. Secondly, the patient had moderate ascites and pericardial effusion. Thirdly, the patient also had an acute renal injury. Thus, patient was already in the compromised state and any further deterioration might lead to further heart failure. IVC was assessed and it was non-collapsible, indicating that the patient was in the fluid overload state. Patient with such a low cardiac contractility (EF 15%) might not have tolerated regional anesthesia. We inserted arterial and central line before induction under local anesthesia for early diagnosis and management of any hemodynamic disturbance during induction. In our case, the effective intraoperative management leads to on-table extubation of the patient after surgery. Based on the existing literature, the choice of anesthesia in such cases is always a dilemma. Our experience suggests that general anesthesia might be a safer choice in such cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.