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Toxidermie à l’étifoxine : peu de changement malgré l’alerte ANSM de 2014 en Haute-Normandie
A646 JACC March 17, 2015 Volume 65, Issue 10S
FIT Clinical Decision Making Peripartum Management of Severe Idiopathic Pulmonary Arterial Hypertension and the Use of Extracorporeal Membrane Oxygenation During Delivery Poster Contributions Poster Hall B1 Saturday, March 14, 2015, 3:45 p.m.-4:30 p.m. Session Title: FIT Clinical Decision Making: Structural Heart Disease and Pulmonary Hypertension Abstract Category: Pulmonary Hypertension and Pulmonary Thrombo-embolic Disease Presentation Number: 1142-152 Authors: Klitos Konstantinidis, Steven Schulman, Johns Hopkins Hospital, Baltimore, MD, USA
Background: Severe idiopathic PAH and some cardiac diseases especially if they are associated with PH and RV dysfunction have an extremely high mortality during pregnancy. Pregnancy is an absolute contraindication in these diseases.
Case: 35 year old female at 37 weeks of pregnancy without previous history was referred after a murmur was heard during an immigration work up. She reported dyspnea, chest pain and near syncope while walking up an incline a week ago. Exam showed regular rhythm, normal rate, elevated JVP, loud S2, 4/6 holosystolic murmur at the RUSB with a thrill, trace leg edema and clear lungs.
Decision Making: TTE showed normal LV function, moderately dilated RV with moderately reduced systolic function, mildly dilated RA with mild TR and PR. RVSP was estimated 82mmHg. RHC showed CO 4.2 L/min, PAP 106/35 mmHg and PCWP 10mmHg. She was admitted in the CICU for hemodynamic optimization before delivery and the diagnosis of idiopathic PAH was made. She was diuresed with CVP goal 6-8mmHg. Epoprostenol IV was started and uptitrated to 7ng/Kg/min. Fetus’ heart rate was continuously externally monitored. Given the severity of the PH and RV dysfunction it was decided to proceed with ECMO cannulation before delivery. Immediately after placenta was removed, BP dropped in the 30s and she was placed on ECMO. TTE showed severe BiV failure with septal motion suggesting significant RV pressure and volume overload. She was aggressively diuresed and daily TTE showed significant recovery of the LV function. ECMO was decannulated within 3 days and she recovered completely.
Conclusion: Description of the peripartum management of a pregnant patient with severe idiopathic PAH and the successful use of “planned” ECMO immediately after placenta removal. Teaching points: 1.Peripartum management of a patient with severe idiopathic PAH. 2.Detrimental effects of autotranfusion immediately after placenta removal in the RV and LV in patients with severe PAH.
3.First case in the literature with successful use of ECMO during delivery in a patient with severe PH. Many cardiac diseases with extremely high mortality during pregnancy are associated with severe PH and RV failure. ECMO could be considered during delivery in these patients.
FIT Clinical Decision Making Peripartum Management of Severe Idiopathic Pulmonary Arterial Hypertension and the Use of Extracorporeal Membrane Oxygenation During Delivery Poster Contributions Poster Hall B1 Saturday, March 14, 2015, 3:45 p.m.-4:30 p.m. Session Title: FIT Clinical Decision Making: Structural Heart Disease and Pulmonary Hypertension Abstract Category: Pulmonary Hypertension and Pulmonary Thrombo-embolic Disease Presentation Number: 1142-152 Authors: Klitos Konstantinidis, Steven Schulman, Johns Hopkins Hospital, Baltimore, MD, USA
Background: Severe idiopathic PAH and some cardiac diseases especially if they are associated with PH and RV dysfunction have an extremely high mortality during pregnancy. Pregnancy is an absolute contraindication in these diseases.
Case: 35 year old female at 37 weeks of pregnancy without previous history was referred after a murmur was heard during an immigration work up. She reported dyspnea, chest pain and near syncope while walking up an incline a week ago. Exam showed regular rhythm, normal rate, elevated JVP, loud S2, 4/6 holosystolic murmur at the RUSB with a thrill, trace leg edema and clear lungs.
Decision Making: TTE showed normal LV function, moderately dilated RV with moderately reduced systolic function, mildly dilated RA with mild TR and PR. RVSP was estimated 82mmHg. RHC showed CO 4.2 L/min, PAP 106/35 mmHg and PCWP 10mmHg. She was admitted in the CICU for hemodynamic optimization before delivery and the diagnosis of idiopathic PAH was made. She was diuresed with CVP goal 6-8mmHg. Epoprostenol IV was started and uptitrated to 7ng/Kg/min. Fetus’ heart rate was continuously externally monitored. Given the severity of the PH and RV dysfunction it was decided to proceed with ECMO cannulation before delivery. Immediately after placenta was removed, BP dropped in the 30s and she was placed on ECMO. TTE showed severe BiV failure with septal motion suggesting significant RV pressure and volume overload. She was aggressively diuresed and daily TTE showed significant recovery of the LV function. ECMO was decannulated within 3 days and she recovered completely.
Conclusion: Description of the peripartum management of a pregnant patient with severe idiopathic PAH and the successful use of “planned” ECMO immediately after placenta removal. Teaching points: 1.Peripartum management of a patient with severe idiopathic PAH. 2.Detrimental effects of autotranfusion immediately after placenta removal in the RV and LV in patients with severe PAH.
3.First case in the literature with successful use of ECMO during delivery in a patient with severe PH. Many cardiac diseases with extremely high mortality during pregnancy are associated with severe PH and RV failure. ECMO could be considered during delivery in these patients.