Combined Spinal and Epidural Anesthesia for Cesarean Section in a Patient with Hypertrophic Obstructive Cardiomyopathy

Abstract

To the Editor: The administration of general anesthesia has been recommended in the management of anesthesia for cesarean section in patients with hypertrophic obstructive cardiomyopathy (HOCM) (1). We present, to our knowledge, the first case of combined spinal and epidural anesthesia for cesarean section in a patient with HOCM. A 35-yr-old primigravida with HOCM underwent elective cesarean section at 32 weeks’ gestation. The patient was monitored with the use of radial and pulmonary artery catheters. Spinal anesthesia was administered with 1.6 mL of isobaric bupivacaine at the L4–L5 interspace. Sensory anesthesia was extended to L2 at 10 min after the spinal injection. Incremental epidural boluses with 2% lidocaine to a total volume of 6 mL and fentanyl 50 μg were injected through an epidural catheter inserted at the T12–L1 interspace to achieve T4 sensory anesthesia. The cesarean delivery was uneventful, and a healthy 1332-g neonate was delivered. After the delivery, decreases in blood pressure from 90/42 to 77/38 mm Hg and in cardiac index from 2.8 to 2.3 L · min−1 · m−2 were observed. Phenylephrine 0.05 mg was administered, and arterial blood pressure returned to 90/40 mm Hg, although CI was 2.4 L · min−1 · m−2. The mother’s fluid loss, including blood and amniotic fluid, was 270 mL; total fluid administration was 1050 mL; and urine output was 400 mL. Small-dose spinal anesthesia combined with epidural anesthesia in small incremental local anesthetic may be beneficial in cesarean section in patients with HOCM. Intraoperative monitoring with pulmonary artery catheter provides prompt titration of intravenous fluid administration (2), and hypotension was successfully treated with phenylephrine. Tadahiko Ishiyama, MD, PhD Takeshi Oguchi, MD, PhD Tetsuya Iijima, MD Takashi Matsukawa, MD, PhD Satoshi Kashimoto, MD, PhD Teruo Kumazawa, MD, PhD