HEART FAILURE AND PREGNANCY: TO DELIVER OR TO CARRY ON

Abstract

SESSION TITLE: Cardiovascular Disease SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Management of acute decompensated heart failure and life-threatening arrhythmias during pregnancy is challenging. Increasing physiological demands of pregnancy and limited pharmacological treatment options often push physicians to pursue early delivery. We report a rare case of cardiomyopathy manifesting as incessant ventricular tachycardia during second trimester of pregnancy. CASE PRESENTATION: A 30 year-old Caucasian female with no past medical history presented to the hospital with shortness of breath, palpitations, and lower extremity swelling during the 26th week of her first pregnancy. Electrocardiogram and telemetry revealed a high burden of non-sustained polymorphic ventricular tachycardia (VT) (figure 1). Patient was transferred to intensive care unit (ICU) and transthoracic echocardiogram (TTE) showed biventricular failure with left ventricular ejection fraction (LVEF) of 20%, severe left atrial dilation and mitral regurgitation (figure 2). Patient was started on esmolol and lidocaine infusions. A pulmonary artery catheter was placed for hemodynamic monitoring (figure 3). Diuresis was also initiated. Given the persistent VT and evidence of lidocaine toxicity, mexiletine was initiated and lidocaine discontinued. After 7 days, the frequency of ventricular ectopic beats significantly decreased. Considering the likelihood of peripartum cardiomyopathy, bromocriptine was administered, but patient could not tolerate it due to worsening hypotension and nausea. With increasing cardiovascular demands of pregnancy and persistent severe cardiomyopathy, a decision was made to pursue caesarian section at 28 weeks. Given the stress of surgery and mortality associated with it, an Impella CP left ventricular assist device was placed immediately prior to caesarian section. Patient tolerated both procedures well and was subsequently weaned off Impella CP device in the surgical ICU. Baby was also viable. Patient was eventually discharged on metoprolol and mexilitine along with standard therapy as well as a LifeVest. Follow up TTE at 4 months showed slight improvement in LEVF at 25%. Cardiac magnetic resonance imaging revealed extensive patchy and transmural late gadolinium enhancement (figure 3). DISCUSSION: Management of incessant ventricular tachycardia in pregnancy can be difficult as amiodarone is associated with fetal growth retardation. Lidocaine, procainamide and mexiletine are the recommend anti-arrhythmic agents for stable cases. In patients with severely depressed LVEF, caesarean section carries a high mortality rate. Preemptive use of circulatory left ventricular assist device such as Impella CP is potentially life saving. CONCLUSIONS: Cardiomyopathy in pregnancy can present as incessant ventricular tachycardia and should alert physician for further work up. Reference #1: Arany Z, and Elkayam U. Peripartum Cardiomyopathy. Circulation. 2016;133(14):1397-409. DISCLOSURES: No relevant relationships by Anthony Lubinsky, source=Web Response No relevant relationships by Assad Oskuei, source=Web Response