A&A practice
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Cardiac disease is one of the leading causes of maternal mortality in developed countries. The presence of a mechanical valve is a predictor of cardiac complications in obstetric patients, likely due to the challenges associated with pregnancy hypercoagulability and the imperative of meticulous management of anticoagulation throughout pregnancy, delivery, and the postpartum and to prevent the devastating event of a mechanical valve thrombosis. We report on the management of a pregnant woman with a mechanical aortic valve found to have a thrombus at 37 weeks gestation. It was decided to perform cesarean delivery to allow for a reoperative mechanical aortic valve replacement 24 hours thereafter.
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Case Reports
Neuraxial Anesthesia in a Patient With a History of Spontaneous Intracranial Hypotension: A Case Report.
One commonly cited complication of neuraxial techniques is postdural puncture headache. Patients with spontaneous intracranial hypotension may present with a similar constellation of symptoms in the absence of any neuraxial instrumentation. The underlying physiology of spontaneous intracranial hypotension is similar to postdural puncture headache, but cerebrospinal fluid leaks may develop spontaneously at multiple levels of the neuraxis due to a variety of proposed mechanisms. We present a patient with a history of spontaneous intracranial hypotension who underwent a total knee arthroplasty under spinal anesthesia without complication and discuss the pathophysiology, proposed etiologies and treatments, and safety of neuraxial anesthesia in spontaneous intracranial hypotension.
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Costello syndrome is a rare genetic disorder characterized by mental and growth retardation and distinctive coarse facies. A significant proportion of patients with Costello syndrome have hypertrophic cardiomyopathy, papillomata, and malignant tumors. ⋯ There have been several reports on the anesthetic management of children with Costello syndrome, but few have reported on the anesthetic management of adults with Costello syndrome. In adults, careful preoperative evaluation as well as preparation for adult-onset and previously unrecognized medical conditions are key for safe anesthetic management.
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Case Reports
Diagnosis of an Additional Ventricular Septal Defect by Observing Dark Blood in Aortic Root Vent: A Case Report.
Diagnosis and management of multiple ventricular septal defects still remain a challenging task. Although many new diagnostic modalities have been used for the perioperative diagnosis of ventricular septal defects, the discovery of residual or additional shunts in the postoperative period is not uncommon. We report a case where we observed an undiagnosed additional ventricular septal defect shunting deoxygenated dark blood into the aortic root vent during deairing of the heart, which was confirmed on transesophageal echocardiography and addressed with reinstitution of cardiopulmonary bypass.
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The recommended duration of dual antiplatelet therapy after drug-eluting stent placement presents a dilemma for patients with recent stenting who require urgent or emergency noncardiac surgery. We present the case of a patient with recent drug-eluting stent placement (<6 months) on dual antiplatelet therapy who underwent successful emergency cervical spine surgery with antiplatelet therapy bridged using cangrelor, an intravenous P2Y12 inhibitor antiplatelet agent. Our experience illustrates the multidisciplinary approach to a patient with high thrombotic and bleeding risk who underwent neurosurgery off both aspirin and a P2Y12 inhibitor.