Graded Epidural Anesthesia for Emergency Cesarean Section in Severe Tricuspid Regurgitation, Pulmonary Hypertension, and Neurofibromatosis Type 1: A Case Report

Abstract

Background. Severe tricuspid regurgitation with pulmonary hypertension makes right ventricular perfusion depend on systemic pressure, and a sudden fall in vascular resistance during anesthesia may cause collapse. Neurofibromatosis type 1 adds neuraxial and airway risks.

Objective. To describe the anesthetic management and hemodynamic course of an emergency Cesarean delivery under a graded epidural in a parturient with these three conditions.

Methods. A 37-year-old woman (G2P1A0, 34 weeks, NYHA class IV) had severe functional tricuspid regurgitation (regurgitant volume 112 mL), echocardiographically estimated pulmonary hypertension (systolic about 79 mmHg, mean about 50 mmHg) and neurofibromatosis type 1. A lumbar epidural catheter was placed (L1–L2), and 0.375% levobupivacaine with fentanyl 50 μg was given in 3 mL aliquots every 5 minutes (12 mL). Crystalloid was limited to 300 mL, with titrated phenylephrine and slow oxytocin. The CARE guideline was followed.

Results. A T6 block without motor block was reached in 20 minutes. Mean arterial pressure stayed at 70–78 mmHg (−2.8% to +8.3%), heart rate fell from 112 to 94 bpm (−16.1%) and oxygen saturation rose from 92% to 98%. A neonate of 2300 g was delivered (Apgar 6, 7 and 8 at 1, 5 and 10 minutes). There was no cardiovascular collapse or airway intervention. She was discharged on day 6.

Conclusion. A slowly titrated epidural was followed by stable hemodynamics and an uneventful recovery. One case cannot show that it protected the right ventricle, because right ventricular pressures and vascular resistances were not measured.