Anesthetic Challenges in Cesarean Delivery of a Pregnant Woman With Severe Left Ventricular Dysfunction: A Case Report

Severe left ventricular dysfunction during pregnancy represents a major challenge for anesthetic management, owing to the physiological cardiovascular changes of pregnancy and the risk of hemodynamic decompensation in the peripartum period. We report the case of a pregnant woman admitted at 26 weeks of gestation with progressive dyspnea, marked lower-limb edema, and signs of pulmonary congestion, with a history of arterial hypertension and prior SARS-CoV-2 infection. Echocardiographic assessment showed a left ventricular ejection fraction of 22%, marked diffuse hypokinesia, severe systolic dysfunction, grade II diastolic dysfunction, moderate mitral regurgitation, and moderate-to-severe pulmonary hypertension. Given the diagnosis of heart failure with reduced ejection fraction and the high cardiovascular risk, the patient was admitted to the intensive care unit and underwent multidisciplinary management, including noninvasive ventilation, diuretic therapy, inotropic support with dobutamine, and subsequent pharmacological optimization with hydralazine, nitrate, and a beta-blocker. After clinical stabilization, she was discharged and remained under specialized follow-up. At approximately 32 weeks, she was readmitted for delivery, clinically compensated, with preserved renal function and coagulation parameters. Cesarean delivery was performed under a sequential neuraxial technique, with an epidural catheter followed by a reduced-dose spinal block with hyperbaric bupivacaine and intrathecal morphine, under invasive blood pressure monitoring through a radial artery catheter, central venous access, and a continuous low-dose dobutamine infusion started before the procedure, with hemodynamic stability maintained throughout surgery. The patient had a stable postoperative course, dobutamine was discontinued 24 hours after the procedure, and she was discharged, although she maintained an ejection fraction close to 20% on cardiology follow-up. This case highlights the importance of preoperative cardiovascular optimization, individualized anesthetic planning, careful fluid management, risk-proportional monitoring, and integration among anesthesiology, cardiology, obstetrics, and intensive care in the management of pregnant women with severe ventricular dysfunction.