Non-invasive cardiac output monitoring for cesarean delivery under epidural anesthesia in a patient with Marfan syndrome and cardiomyopathy

•Cardiomyopathy can predispose parturients to acute heart failure at delivery.•Non-invasive cardiac output monitoring may be useful for high-risk parturients.•Hypovolemia and slow oxytocin administration may delay increases in cardiac output at delivery.•In our case, mean arterial pressure and heart rate did not correlate with cardiac output trends.

Maternal cardiac output and stroke volume increase significantly at the time of cesarean delivery. Parturients with baseline myocardial dysfunction are at increased risk of cardiovascular decompensation in the peripartum period and close hemodynamic monitoring is warranted. We report our use of intraoperative non-invasive cardiac output monitoring during cesarean delivery under epidural anesthesia in a 24-year-old woman with dilated cardiomyopathy secondary to Marfan syndrome, aortic arch, aortic valve and mitral valve replacements and a left ventricular ejection fraction of 37%. Three distinct hemodynamic trends were noted. After achieving adequate surgical anesthesia with 2% lidocaine 20 mL, cardiac output and stroke volume rose for approximately 20 min from baseline values of 6.3 L/min and 69 mL, respectively, to 9 L/min and 107 mL. Values subsequently trended down and remained depressed for nearly 20 min following delivery. The lack of immediate post-delivery increases in both cardiac output and stroke volume were attributed to acute blood loss, intravascular volume depletion from fluid restriction, and slow infusion of oxytocin. By the end of surgery, cardiac output and stroke volume ultimately increased by 66% and 84% of baseline values, respectively. Systemic blood pressure, heart rate and cardiac output did not appear to correlate despite the use of phenylephrine to manage hypotension. The patient remained hemodynamically stable with no evidence of acute volume overload.