EComment. Left tilt position for cardiopulmonary bypass in parturient patients

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We read with great interest the paper by Ngatchou et al [1]. The 28-year old pregnant woman underwent a successful implantation of a veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome of unknown origin. The insertion of the right and the left venous femoral cannula was facilitated by placing a wedge-shaped cushion under the right hip. The authors stated that the left tilt position used in this case report is recommended for pregnant women in two situations: in a caesarean section and in cardiopulmonary resuscitation. However, the left lateral tilt position is also recommended in parturients undergoing cardiopulmonary bypass (CPB) for cardiac surgery. Reducing the compression of the inferior vena cava by the foetus is mandatory to allow for better venous return during CBP. This will prevent hypotension that occurs in case of poor venous return when the circulation goes from corporeal to extracorporeal. The collapse of peripheral resistance can bring about a brisk decrease of the mean arterial pressure and a secondary reduction of placental perfusion. In the current era, CPB during pregnancy can be performed with relative safety when performed at tertiary centers with the expertise [2]; however it is still associated with substantial morbidity and mortality [3]. We would like to share our experience relating to two parturients operated on an emergent basis with the use of CPB during the last three years at our institution and to highlight the important role of the left lateral tilt position during CPB. A 30-year-old woman at 26 weeks of gestation was admitted because of the acute onset of severe chest pain. Echocardiography revealed a tricuspid aortic valve with mild aortic regurgitation, and an acute aortic dissection involving the ascending aorta, which was also verified by a computed tomography scan. CPB was instituted between the right atrium and the right axillary artery. Hypothermia was avoided and the operation consisted of replacing the supracoronary ascending aorta. A 39-year-old woman underwent a successful pulmonary embolectomy at the 27th week of pregnancy. We performed surgical pulmonary embolectomy under CPB to restore adequate hemodynamic stability and to relieve strain on the right ventricle [4]. In both cases, the left lateral tilt position was applied and the venous return was very satisfactory. The pregnancies were carried to term and healthy newborns at 36 and 38 weeks of gestation were delivered, respectively. Conflict of Interest: None declared.