Epidural anesthesia with the trendelenburg position for cesarean section with or without a cardiac surgical procedure in patients with severe mitral stenosis: A hemodynamic study

The hemodynamic effects of epidural anesthesia (EA) with the Trendelenburg position were studied in seven patients with severe mitral stenosis undergoing emergency cesarean section (CS) because of hemodynamic deterioration. In six patients, the CS was immediately followed by an open mitral commissurotomy under general anesthesia, whereas in one patient, the CS was performed alone. A significant reduction in heart rate (120 ± 5 to 83 ± 7 beats/min; P < 0.001) was observed after induction of EA. Mean arterial pressure (MAP) decreased (78 ± 9 to 55 ± 5 mm Hg; P < 0.01) simultaneously with reduction of the pulmonary capillary wedge pressure (PCWP) (37 ± 4 to 15 ± 4 mm Hg, P < 0.001) and cardiac index (CI) (2.4 ± 0.3 to 1.8 ± 0.32 L/min/m²; P < 0.001). However, PCWP could be adjusted by selecting the appropriate angle of the Trendelenburg position. When the PCWP was approximately 25 mm Hg, MAP and CI increased to 72 ± 7 mm Hg and 3.1 ± 0.4L/min/m², respectively, and a satisfactory hemodynamic state was achieved. Systemic vascular resistance decreased after induction of EA (2,250 ± 250 to 1,750 ± 450 dyne · s · cm^-5; P < 0.001), and remained unchanged during the perioperative period. It is concluded that the combination of epidural anesthesia with tilting of the table is a safe method for urgent CS in pregnant women with critical mitral stenosis in whom termination of pregnancy is indicated because of hemodynamic deterioration.