Epidural anesthesia with the trendelenburg position for cesarean section with or without a cardiac surgical procedure in patients with severe mitral stenosis: A hemodynamic study

Anesthesia in pregnancy with heart disease

“…However, in one case report, alfentanil provided hemodynamic stability and allowed for immediate postoperative extubation but caused neonatal respiratory depression. [41] Epidural anesthesia with 0.5% bupivacaine has been given successfully in women undergoing urgent cesarean delivery for hemodynamic deterioration from severe MS.[44] Each patient was placed in 15° head down position to maintain the PCWP at 25 mmHg.…”

Anesthetic and analgesic management of mitral stenosis during pregnancy

“…Because patients with MS may have a limited ability to increase CO, prevention of aortocaval compression or rapid decreases in SVR maintains venous return, PCWP, and left ventricular enddiastolic volume at near baseline levels, which, in turn, limit the need for compensatory increases in cardiac output. 16,17 Labor epidural analgesia and CSEA have been administered successfully in carefully monitored parturients with MS when epidural local anesthetic is titrated incrementally and when combined with intrathecal or epidural opioids. [13][14][15][17][18][19][20][21] Kee et al 19 reported, in 3 parturients with moderately severe MS, the use of intrathecal fentanyl (25 g) followed by diluted epidural bupivacaine and fentanyl infusion, without significant hemodynamic changes or requirement of local anesthetic boluses.…”

“…16,17 Labor epidural analgesia and CSEA have been administered successfully in carefully monitored parturients with MS when epidural local anesthetic is titrated incrementally and when combined with intrathecal or epidural opioids. [13][14][15][17][18][19][20][21] Kee et al 19 reported, in 3 parturients with moderately severe MS, the use of intrathecal fentanyl (25 g) followed by diluted epidural bupivacaine and fentanyl infusion, without significant hemodynamic changes or requirement of local anesthetic boluses. 19 We chose a CSEA 19 in an attempt to minimize initial sympathetic block and hypotension during the first stage of labor.…”

“…During the second stage of labor or an operative delivery, epidural anesthesia and analgesia can facilitate the gradual increase of venous capacitance to accommodate the acute increases in venous return and CO that occur in the immediate postpartum period and lead to pulmonary edema. Ziskind et al 17 showed that parturients with severe MS benefited from epidural anesthesia with appropriate degrees of Trendelenburg position to obtain optimal PCWP pressure and cardiac indexes and reduce maternal heart rate during operative delivery. Clark reported PCWP increases of 10 to 18 mm Hg in the immediate postpartum period after vaginal delivery in parturients with severe MS. 14 In addition, he suggested that intravenous albumin may increase plasma colloid oncotic pressure and limit the development of pulmonary edema.…”

Anesthesia for the parturient with cardiovascular disease

“…These patients may be prone to hypotension with epidural anesthesia, secondary to a combination of venous pooling and prior beta-adrenergic blockade and diuretic therapy. 22 The usual vasopressor choice of ephedrine should be avoided, as it may result in tachycardia. Instead, judicious use of metaraminol or low-dose (20-40 mcg) phenylephrine assists in restoration of maternal blood pressure with little or no unwanted effect on uteroplacental perfusion.…”