Spinal Anesthesia in a Term Parturient with Repaired Coarctation of Aorta: Navigating Hemodynamics with Precision

Dear Editor, Pregnancy in patients with congenital heart disease presents a delicate challenge in anesthetic management, more so when it involves complex vascular lesions such as coarctation of the aorta (CoA). We report the successful anesthetic management of a 30-year-old primigravida with repaired postductal CoA who underwent an uneventful caesarean delivery under spinal anesthesia. Primi, at 38 weeks gestation, had been diagnosed with severe postductal CoA 2 years prior and underwent successful percutaneous transluminal angioplasty with stenting. She was maintained on metoprolol and low-dose aspirin during pregnancy, with the latter discontinued before surgery. Patient’s clinical evaluation showed well-preserved functional status, no signs of cardiac decompensation, and blood pressure discrepancy of ~30 mmHg between upper and lower limbs (UL BP: 150/80 mmHg, LL BP: 120/80 mmHg), consistent with residual gradient across the stented segment. Echocardiography revealed a peak gradient of 38 mmHg across the aorta, trivial mitral and tricuspid regurgitation, mild concentric left ventricular hypertrophy, and preserved biventricular function. The cardiologist advised withholding aspirin and metoprolol before delivery. After comprehensive multidisciplinary discussion and risk assessment, spinal anesthesia was chosen.[1] A low-dose, single-shot spinal with 2 ml of 0.5% heavy bupivacaine was administered in the left lateral position. Hemodynamic parameters remained stable throughout the 105-minute surgery. Of particular interest was the intraoperative monitoring of both upper and lower limb noninvasive blood pressures, which revealed a persistent systolic differential of 20–28 mmHg, confirming residual segmental vascular resistance poststenting. Despite this, there was no evidence of compromised distal perfusion or reflex tachycardia, highlighting the success of graded neuraxial anesthesia and fluid restriction in mitigating cardiovascular stress. Intraoperative fluid was restricted to 900 ml to prevent volume overload, and blood loss was estimated at 500 ml. Perioperatively, no adverse cardiac or neurological events occurred. She was discharged on postoperative day 3 with uneventful recovery. This case underscores the importance of tailored anesthetic strategies in high-risk parturient. Traditionally, neuraxial anesthesia in CoA has been approached cautiously due to the risk of abrupt hypotension, reduced preload, and compromised distal perfusion.[2,3] However, in selected, stable patients with repaired lesions and good ventricular function, spinal anesthesia with meticulous planning and dose titration can be safe and effective. Notably, the residual gradient and vascular reactivity in our patient remained well-compensated, reflecting the success of prior intervention and allowing for a less invasive anesthetic choice.[4] Furthermore, continuous noninvasive monitoring of both upper and lower limb pressures provided valuable intraoperative insights.[5] Future prospective studies should explore whether intraoperative BP gradient monitoring can serve as a surrogate for stent patency and cardiovascular load in high-risk obstetric populations. Postspinal hypotension must be carefully managed, especially when there is a significant difference in blood pressure between the upper and lower limbs, as this can reduce uterine blood flow and potentially compromise the fetus. With growing survival rates of congenital heart disease patients into reproductive years, anesthesiologists must be equipped to manage such challenging but increasingly common scenarios.[6] This case reinforces that spinal anesthesia, once considered risky in CoA, can be safely administered in carefully selected patients with repaired lesions and good functional status. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.