warfarin and Heart-Septal-Defects--Ventricular

Spontaneous spinal epidural hematoma (SSEH) is considered to be a relatively rare disease that can result in serious neurological sequelae. The pathogenesis and risk factors of SSEH are still unknown, and its differential diagnosis varies widely. Misdiagnosis with more common conditions such as stroke or aortic syndromes can occur. We report the case of a 27-year-old man who developed sudden upper back pain with no specific precipitant. Five days later, he visited our emergency department complaining of weakness in both lower limbs and dysuria. He had a history of intracardiac repair and a Blalock-Park procedure for an interrupted aortic arch and ventricular septal defect in infancy. Additionally, he had undergone an aortic root dilatation and aortic valve replacement at the age of 10 because of progression of aortic and supra-aortic stenosis and had received chronic anticoagulation and antiplatelet therapy with warfarin and aspirin, respectively. An emergency spine magnetic resonance imaging scan indicated a mass at the Th3-Th5 level with severe compression of the dural sac and the spinal cord. Emergency excision showed a spinal epidural hematoma. Mild postoperative gait disturbance and dysuria persisted, requiring rehabilitation and intermittent self-urethral catheterization. As patients with adult congenital heart disease have an increased risk of bleeding, they may be at risk of developing SSEH. However, this is the first report to describe such an association.

Topics: Adult; Anticoagulants; Aortic Valve Stenosis; Aspirin; Heart Defects, Congenital; Heart Septal Defects, Ventricular; Heart Valve Prosthesis Implantation; Hematoma, Epidural, Spinal; Humans; Magnetic Resonance Imaging; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Warfarin

Topics: Abnormalities, Multiple; Anticoagulants; Bioprosthesis; Cardiac Surgical Procedures; Drug Administration Schedule; Female; Follow-Up Studies; Heart Defects, Congenital; Heart Septal Defects, Ventricular; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Infant; Postoperative Care; Thromboembolism; Time Factors; Treatment Outcome; Tricuspid Valve Insufficiency; Warfarin

This is the report of a series of eight patients with pulmonary hypertension (primary and secondary) who delivered at the McMaster University Medical Centre between 1978 and 1987. Seven of the eight patients delivered vaginally and had a successful outcome. The eighth patient was admitted as an emergency and died shortly after Caesarean section under general anaesthesia, performed to save the infant. The other seven patients were all managed by a team, including anaesthetists, cardiologists and obstetricians, from about 25 wk. The patients were hospitalized pre-partum and received oxygen therapy and anticoagulation with heparin. Analgesia in labour was managed, once anticoagulation was reversed, by low concentrations of epidural bupivacaine (0.125%-0.375%) and fentanyl. The patients were monitored during labour and delivery with oximetry and arterial and central venous pressure lines. Pulmonary arterial lines were not used because of increased risk and questionable usefulness. Vaginal delivery was managed with vacuum extraction or forceps lift-out to minimize the stress of pushing. After delivery, all patients were monitored in an intensive care unit for several days, anticoagulation was restarted, and all patients were discharged home taking oral anticoagulant therapy. The successful management of pulmonary hypertension in pregnancy should include team management started early in pregnancy and controlled vaginal delivery utilizing epidural analgesia.

Topics: Adult; Anesthesia, Epidural; Anesthesia, Obstetrical; Delivery, Obstetric; Ductus Arteriosus, Patent; Eisenmenger Complex; Female; Heart Septal Defects, Atrial; Heart Septal Defects, Ventricular; Heart Valve Diseases; Heparin; Humans; Hypertension, Pulmonary; Mitral Valve; Monitoring, Physiologic; Obstetric Labor Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Warfarin