A 36 year old woman attending antenatal clinic at 16 weeks pregnant was found to have a murmur, alongside shortness of breath, and was therefore referred for echocardiography and subsequently CT imaging.
She was found to have a Debakey Type II dissection from the sinus of valsalva to the proximal arch at the level of the innominate artery, with severe aortic regurgitation. The aortic root measured 7cm. The patient was not in heart failure but had collapsing radial pulses and carotids.
Surgery was therefore necessary and a valve sparing root, ascending aorta and hemi-arch repair was performed using deep hypothermic circulatory arrest (DHCA).
The risk of surgery to the mother and foetus was 2-3% and 16-30%, respectively, depending on the extent of surgery and the need for deep hypothermic circulatory arrest.
Previous renal transplantation in 2011 also added to the risk of surgery and the risk of renal graft loss was <10% with a higher risk of temporary renal dysfunction.
Perfusion strategy involved using a blood prime, cardiac index of 3 L/min/m2, gently cooling the patient down to 22oC, blood pressure maintenance between 65-75mmHg with a noradrenaline infusion running throughout, limited vasoconstrictor use, alpha stat PH management, and increased target haemoglobin levels.
The patient had good LV and RV function post operatively with mild aortic regurgitation and was extubated overnight. Her kidney function was also normal. The following day a foetal scan reported a viable foetus with normal liquor volume, and foetal movements were seen.
The baby was born at 34 weeks by Caesarean section for spontaneous onset of labour with mother and baby doing well.
This case highlights difficulties and potential strategies in a case of this kind requiring DHCA in complex surgery involving pregnant patients.
Louise is a Senior Clinical Perfusionist at the Queen Elizabeth Hospital, Birmingham. She has gained a BSc in Medical Sciences followed by an MSc in Perfusion Science. She has worked as a Perfusionist at both Trent Cardiac Centre, Nottingham and Birmingham Children's Hospital before joining the Queen Elizabeth in Birmingham and has experience in both Adult and Paediatric Cardiopulmonary Bypass and ECMO.