Anesthetic Management in Patients Undergoing Cesarean Section with Heart Failure Comorbid due to Rheumatic Heart Disease

Introduction: The anesthetic technique commonly used in cesarean section is spinal anesthesia; however the use of spinal anesthesia is relatively contraindicated in patients with severe mitral stenosis due to the risk of hemodynamic instability. Case Report: We reported a case of a 31-year-old woman who presented with shortness of breath during rest and worsened with activity. Cardiovascular examination showed arrhythmia, with systolic murmur on apex area. Electrocardiography examination showed atrial fibrillation with heart rate of 75x/minutes, right axis deviation, with occasional PVC. Echocardiography showed normal LV size (normal wall motion all segment), severely dilated LA, mildly dilated RA, normal RV size, LVEF BP 58.6%, LV diastolic function undetermined, TAPSE 15 mm, eRAP 8mmHg, severe MS, moderate MR, Mild AR, moderate TR. Patients was assessed with ASA physical state III and planned to undergo elective cesarean section under epidural anesthesia. Epidural anesthesia was done using 0, 375% Bupivacaine with volume of 25 ml via epidural catheter. The epidural catheter was placed at 1st-2ndlumbal vertebra level; the length of the catheter in the epidural space was 5 cm with a target tip at 11ththoracal vertebra level, dermatome target of 10ththoracal vertebra to 1stlumbal vertebra level and viscerotome target of10ththoracal vertebra to 2ndlumbal vertebra level. During surgery, hemodynamic fluctuations were controlled without additional medication. The patient was then given epidural bupivacaine 0.0625% and morphine 0, 5 mg volume 10 mL every 10-12 hours and Paracetamol 1 g every 8 hours IV for post-operative analgesia, and was treated in the intensive care unit for close monitoring. Discussion: The choice of anesthetic technique in patients with mitral stenosis should be considered according to the hemodynamic status of the patient at the time of arrival, the type of heart disease, previous drug use and whether the surgery can be elective or must be an emergency. In hemodynamically stable patients, epidural anesthesia or a combination of low-dose epidural-spinal anesthesia is preferable to general anesthesia. Conclusion: Epidural anesthesia is the most preferred anesthetic technique for pregnant patients with rheumatic heart disease undergoing cesarean section.