Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942007000600009
Brazilian Journal of Anesthesiology
Clinical Information

Anestesia para cesariana em paciente portadora de cardiomiopatia hipertrófica familiar: relato de caso

Anesthesia for cesarean section in a patient with familiar hypertrophic cardiomyopathy: case report

Renato Mestriner Stocche; Luis Vicente Garcia; Jyrson Guilherme Klamt

http://dx.doi.org/10.1590/S0034-70942007000600009 Braz J Anesthesiol, vol.57, n6, p.665-671, 2007
PDF Português
PDF English
Downloads: 0
Views: 1114

Resumo

JUSTIFICATIVA E OBJETIVOS: A cardiomiopatia hipertrófica familiar (CHF) é uma doença cardíaca rara, com transmissão hereditária, caracterizada por hipertrofia do septo ventricular e grau variável de estenose aórtica subvalvar. Nessa doença, o aumento da contratilidade do miocárdio e a diminuição da resistência vascular periférica podem agravar a obstrução da via de saída do VE, produzindo disritmia e isquemia cardíaca. Este relato objetivou discutir o manuseio anestésico para cesariana em paciente com CHF. RELATO DO CASO: Paciente com 33 semanas de gestação e diagnóstico prévio de CHF apresentou no holter de 24 horas 22 episódios de taquicardia ventricular não-sustentada (TVNS) e dois episódios de taquicardia ventricular sustentada (TVS). Referia episódios de palpitação, dispnéia e dor precordial de curta duração. A paciente foi medicada com atenolol e apresentou controle dos sintomas e das disritmias cardíacas. Com 38 semanas e 5 dias de gestação a paciente foi submetida à cesariana eletiva. Além do habitual a monitorização contou com análise de segmento ST e pressão arterial invasiva. Utilizou-se anestesia raquiperidural com injeção de 5 µg de sunfentanil na raqui seguida de administração de bupivacaína a 0,375% em doses de incremento até atingir altura de T6 (total de 16 mL). Utilizou-se metaraminol como vasopressor. Não houve hipotensão arterial materna ou outras complicações no perioperatório. CONCLUSÕES: A anestesia geral é freqüentemente utilizada para cesarianas de pacientes com CHF. A anestesia raquiperidural com instalação lenta do bloqueio foi uma alternativa segura. Nessas pacientes, o aumento da contratilidade miocárdica deve ser evitado, devendo-se, se necessário, utilizar-se um a-agonista para correção de hipotensão arterial materna.

Palavras-chave

CIRURGIA, Obstétrica, DOENÇAS, Cardíaca, TÉCNICAS ANESTÉSICAS, Regional

Abstract

BACKGROUND AND OBJECTIVES: Familiar Hypertrophic cardiomyopathy (FHC) is a rare hereditary cardiac disorder characterized by hypertrophy of the ventricular septum and variable degrees of subvalvular aortic stenosis. In this disease, the increase in myocardial contractility and reduction in peripheral vascular resistance can aggravate left ventricular outlet obstruction, leading to arrhythmias and cardiac ischemia. The objective of this report was to discuss the anesthetic management of cesarean section in a patient with FHC. CASE REPORT: A patient in the 33rd week of pregnancy and prior diagnosis of FHC presented, on the 24-hour Holter monitor, 22 episodes of non-sustained ventricular tachycardia (NSVT) and 2 episodes of sustained ventricular tachycardia (SVT). She complained of episodes of palpitation, dyspnea, and chest pain of short duration. The patient was medicated with atenolol, with control of symptoms and cardiac arrhythmias. Within 38 weeks and 5 days of gestation, the patient underwent elective cesarean section. Besides the usual monitoring, analysis of the ST segment and invasive blood pressure were also instituted. Anesthesia consisted of combined spinal-epidural technique with subarachnoidal administration of 5 µg of sufentanil followed by the administration of increasing doses of 0.375% bupivacaine until it reached the level of T6 (total of 16 mL). Metaraminol was used as a vasopressor. Perioperative maternal hypotension or other complications were not observed. CONCLUSIONS: General anesthesia is often used for cesarean sections in patients with FHC. Spinal-epidural anesthesia with slow installation of the blockade was a safe alternative. In those patients, one should avoid an increase in myocardial contractility and, if necessary, a a-agonist should be used to treat maternal hypotension.

Keywords

ANESTHETIC TECHNIQUES, Regional, DISEASES, Cardiac, SURGERY, Obstetric

References

Jackson JM, Thomas SJ. Valvular Heart Disease. Cardiac Anesthesia. 1993:644-650.

Maron BJ, Roberts WC, Epstein SE. Suddem death in hypertrophic cardiomyophaty: a profile of 78 patients. Circulation. 1982;52:1388-1394.

Pelliccia F, Cianfrocca C, Gaudio C. Sudden death during pregnancy in hypertrophic cardiomyopathy. Eur Heart J. 1992;13:421-423.

Gambling DR, Huckell VF. Structural Heart Disease. Obstetric Anesthesia and Uncommon Disorders. 1998:16-17.

Shah DM, Sunderji SG. Hypertrophic cardiomyopathy and pregnancy: report of a maternal mortality and review of literature. Obstet Gynecol Surv. 1985;40:444-448.

Autore C, Spirito P. Approach to hypertrophic cardiomyopathy. Curr Treat Options Cardiovasc Med. 2004;6:489-498.

Oakley GDG, McGarry K, Limb DG. Management of pregnancy in patient with hypertrophic cardiomyopathy. Br Med J. 1979;1:1749-1750.

Autore C, Brauneis S, Apponi F. Epidural anesthesia for cesarean section in patients with hypertrophic cardiomyopathy: a report of three cases. Anesthesiology. 1999;90:1205-1207.

Mangano DT. Anesthesia for the Pregnant Cardiac Patient. Anesthesia for Obstetrics. 1993:511-512.

Ngan Kee WD, Lau TK, Khaw KS. Comparison of metaraminol and ephedrine infusions for maintaining arterial pressure during spinal anesthesia for elective cesarean section. Anesthesiology. 2001;95:307-313.

Nam E, Toque Y, Quintard JM. Use of transesophageal echocardiography to guide the anesthetic management of cesarean section in a patient with hypertrophic cardiomyopathy. J Cardiothorac Vasc Anesth. 1999;13:72-74.

Wilansky S, Belcik T, Osborn R. Hypertrophic cardiomyopathy in pregnancy: The use of two-dimensional and Doppler echocardiography during labor and delivery: a case report. J Heart Valve Dis. 1998;7:355-357.

Paix B, Cyna A, Belperio P. Epidural analgesia for labour and delivery in a parturient with congenital hypertrophic obstructive cardiomyopathy. Anaesth Intensive Care. 1999;27:59-62.

Kazimuddin M, Vashist A, Basher AW. Pregnancy-induced severe left ventricular systolic dysfunction in a patient with hypertrophic cardiomyopathy. Clin Cardiol. 1998;21:848-850.

Tessler MJ, Hudson R, Naugler-Colville M. Pulmonary oedema in two parturients with hypertrophic obstructive cardiomyopathy (HOCM). Can J Anaesth. 1990;37(4):469-473.

Boutroy MJ. Fetal and neonatal effects of the beta-adrenoreceptor blocking agents. Dev Pharmacol Ther. 1987;10:224-231.

5dd81bd10e8825367413f287 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections