{
  "abstract": "Introduction Cardiac disease remains one of the leading causes of maternal morbidity and mortality worldwide, particularly in developed countries where maternal mortality from hemorrhage and infection has been significantly reduced. Pregnancy imposes profound physiological changes on the cardiovascular system, which may unmask or exacerbate pre-existing cardiac conditions. The management of labor and delivery in parturients with cardiac disease presents a unique challenge to anesthesiologists, requiring a delicate balance between maternal hemodynamic stability and adequate analgesia or anesthesia. Regional anesthesia, particularly neuraxial techniques such as epidural and spinal anesthesia, plays a central role in obstetric anesthesia. In women with cardiac disease, these techniques must be tailored to minimize cardiovascular stress and avoid exacerbation of the underlying pathology. Cardiovascular Changes During Pregnancy During pregnancy, the cardiovascular system undergoes significant changes to accommodate the increased metabolic demands of the mother and fetus. These changes include a 30–50% increase in blood volume and cardiac output, a decrease in systemic vascular resistance (SVR), increased heart rate by 10–20 beats per minute, enhanced venous return and increased stroke volume. In healthy parturients, these changes are well tolerated. However, in those with cardiac disease, particularly those with limited cardiac reserve, these adaptations can lead to decompensation. The increased blood volume and cardiac output can precipitate heart failure, while the decreased SVR may exacerbate outflow obstruction in conditions such as aortic stenosis. Classification and Risk Stratification Cardiac disease in pregnancy can be broadly classified into congenital heart disease (CHD) and acquired heart disease, such as valvular heart disease, cardiomyopathy, and ischemic heart disease. Risk stratification tools such as the modified World Health Organization (WHO) classification of maternal cardiovascular risk and the CARPREG II risk score help guide the management of these patients. Categories range from WHO class I (minimal risk) to WHO class IV (extremely high risk, pregnancy contraindicated). Goals of Anesthetic Management The primary goals in anesthetic management of parturients with cardiac disease include minimizing myocardial oxygen demand, maintaining stable hemodynamics (through avoidance of tachycardia, hypotension, and hypertension), ensuring adequate oxygen delivery to the mother and fetus, preventing volume overload and pulmonary edema and finally providing effective pain relief to avoid sympathetic stimulation Advantages of Regional Anesthesia Regional anesthesia, particularly neuraxial techniques, provides several advantages in managing parturients with cardiac disease such as provision of effective analgesia which reduces pain-induced sympathetic stimulation, tachycardia, and hypertension and avoidance of airway manipulation and associated risks of general anesthesia. Furthermore, gradual onset (especially with epidural) allows titration and control of hemodynamic responses. An additional advantage is the lower risk of thromboembolic events compared to general anesthesia, while the ability to use low-dose local anesthetics combined with opioids minimizes motor blockade and allows for better maintenance of venous return. Concerns and Contraindications Despite its benefits, regional anesthesia must be approached cautiously in cardiac patients. Potential concerns include sudden drops in SVR and preload due to sympathetic blockade, which may cause hypotension and decompensation in fixed cardiac output states (e.g., aortic stenosis). Additionally, there may be potentail risks associated with anticoagulation (e.g., epidural hematoma), incomplete analgesia leading to sympathetic overactivity and difficulty in positioning due to orthopnea in patients with heart failure. Absolute contraindications of regional anesthesia include uncorrected severe aortic stenosis, severe hypovolemia, and infection at the injection site. Relative contraindications include coagulopathy, thrombocytopenia, and anticoagulation therapy. Epidural anesthesia Epidural anesthesia is often preferred over spinal anesthesia in high-risk cardiac parturients due to its slower onset and ability to titrate dosing. Benefits include its gradual onset which reduces the risk of abrupt hypotension, the fact that epidural allows for continuous infusion or incremental boluses and finally the ability of the epidural technique to be maintained throughout labor and used for cesarean delivery if needed. Careful preload and positioning are essential to avoid aortocaval compression. Invasive hemodynamic monitoring (e.g., arterial line, central venous pressure) may be indicated depending on the severity of disease. Spinal Anesthesia Spinal anesthesia, although widely used for cesarean delivery in healthy parturients, is generally avoided or used with extreme caution in high-risk cardiac patients due to the potential for abrupt hemodynamic changes. If used, modifications include low-dose or combined spinal-epidural (CSE) techniques, the slow injection of anesthetic agents and the requirement for close hemodynamic monitoring and availability of vasopressors. Combined Spinal-Epidural (CSE) Anesthesia CSE anesthesia allows for rapid onset of spinal anesthesia with the flexibility of extending the block via the epidural catheter. This technique can be advantageous in cardiac parturients if low-dose spinal anesthesia is used, followed by epidural top-ups as needed. It combines the benefits of both techniques but requires meticulous planning and monitoring. General Anesthesia General anesthesia is reserved for situations where regional techniques are contraindicated or fail. It poses several risks to the cardiac patient such as the increased myocardial oxygen demand from intubation and extubation responses, the risk of aspiration and airway complications, the potential for negative inotropic effects of induction agents. Therefore, careful selection of induction agents, short-acting opioids, and vasopressors is crucial. Close hemodynamic monitoring and a multidisciplinary team are essential. Monitoring and Hemodynamic Management Monitoring strategies should be individualized based on disease severity. Basic monitoring includes non-invasive blood pressure, pulse oximetry and electrocardiography. On the other hand, advanced monitoring may include an arterial line for beat-to-beat blood pressure monitoring, central venous pressure monitoring, echocardiography (transesophageal or transthoracic) or in extreme case the requirement for pulmonary artery catheterization. Hemodynamic management often requires a careful balance of fluids and vasoactive drugs. Agents such as phenylephrine or norepinephrine may be used to maintain blood pressure, depending on the underlying cardiac pathology. Postpartum Management The immediate postpartum period is critical due to autotransfusion from the contracting uterus and mobilization of extravascular fluid, which can precipitate volume overload and heart failure. Key considerations include close monitoring in a high-dependency or intensive care unit, jJudicious fluid management, the requirement for diuresis if signs of pulmonary congestion occur and finally the continuation of anticoagulation or heart failure therapy as needed. Multidisciplinary Approach Optimal outcomes are achieved through a multidisciplinary team approach, including many specialties such as obstetricians, anesthesiologists, cardiologists, intensivists and neonatologists. Pre-delivery planning, early epidural placement, continuous monitoring, and preparedness for emergency interventions are vital components of care. Conclusion Regional anesthesia is a cornerstone in the management of parturients with cardiac disease, offering numerous benefits when carefully planned and executed. The choice and administration of anesthesia must be tailored to the individual’s cardiac pathology, functional status, and obstetric considerations. Through a multidisciplinary approach, vigilant monitoring, and judicious use of regional techniques, maternal and fetal outcomes can be optimized even in the context of significant cardiac disease.",
  "authors": [
    {
      "affiliations": [
        "Department of Anesthesiology and Pain Medicine, Aretaieion University Hospital, National and Kapodistrian University of Athens, Greece, Athens, Greece"
      ],
      "name": "Kassiani Theodoraki"
    }
  ],
  "title": "FT34 Regional anesthesia and cardiac disease",
  "uid": "5839c70f-28c1-5b9a-b0c3-07c20f9a9e81"
}