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Table of Contents
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 145-146

Sequential combined spinal epidural anesthesia in a parturient with congenitally corrected transposition of the great arteries

1 Department of Neuroanaesthesia, Max Super Speciality Hospital, Delhi, India
2 Department of Anaesthesiology, Jawaharlal Nehru Medical College, Ajmer, Rajasthan, India

Date of Submission14-Dec-2020
Date of Decision02-Feb-2021
Date of Acceptance09-Feb-2021
Date of Web Publication16-Apr-2021

Correspondence Address:
Dr. Saurav Singh
Department of Neuroanaesthesia, Max Super Speciality Hospital, Patparganj, Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoa.bjoa_261_20

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How to cite this article:
Singh S, Mathur PR. Sequential combined spinal epidural anesthesia in a parturient with congenitally corrected transposition of the great arteries. Bali J Anaesthesiol 2021;5:145-6

How to cite this URL:
Singh S, Mathur PR. Sequential combined spinal epidural anesthesia in a parturient with congenitally corrected transposition of the great arteries. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Jun 23];5:145-6. Available from: https://www.bjoaonline.com/text.asp?2021/5/2/145/313896


Congenitally corrected transposition of great arteries (CC-TGA) is an acyanotic congenital heart disease (CHD) with a prevalence of <1% of all CHD. It is characterized by atrioventricular and ventriculoarterial discordance.[1],[2] More than 90% of cases are associated with other cardiac anomalies.[3] Patients with CC-TGA are at increased risk for heart failure as adults due to progressive decline in systemic right ventricular function. Moreover, hemodynamic stress of pregnancy, labor, and delivery may further aggravate the decline.[1]

A 26-year-old acynotic parturient presented to us in 33 weeks of pregnancy for elective cesarean section. Her history revealed CC-TGA with moderate-to-severe pulmonary stenosis (peak gradient 89 mmHg), ventricular septal defect, mild tricuspid regurgitation, and normal ventricular function, shortness of breath on more than regular activity, and history of hypothyroidism. Cardiovascular examination revealed continuous murmur in mitral and pulmonary area and a normal electrocardiograph. All other routine investigations were normal.

Elective cesarean section was planned under sequential spinal-epidural anesthesia. Maintaining strict aseptic precautions, epidural space was identified using the loss of resistance technique with saline followed by a 27G spinal needle at L4–L5 intrathecal space, utilizing a needle-through-needle method (combined spinal-epidural block). Subarachnoid block was given using 5 mg of 0.5% hyperbaric bupivacaine and 25 μg fentanyl. The epidural catheter was then inserted, followed by 20 mg of 0.5% plain bupivacaine. The patient was made to lie in a supine position for 10 min. The block achieved up to the T6 dermatome level.

Intraoperative vitals were maintained throughout with no complications. Postoperative period analgesia was achieved with 0.125% bupivacaine 8 ml and 20 μg of fentanyl through epidural catheter on a demand basis. The postoperative event was uneventful, and the patient was discharged along with her baby 7 days after delivery.

Significant physiological changes occur during pregnancy, which tends to have an adverse outcome in a woman with CC-TGA.[4] Comprehensive preoperative cardiac evaluation is advisable. Neuraxial anesthesia is preferred over general anesthesia to avoid the stress-induced increase in systemic and pulmonary vascular resistance, the myocardial depressant effects of anesthetic agents, and the detrimental effects of positive pressure ventilation. Intrathecal block produces significant hemodynamic compromise, while epidural anesthesia produces a slower, unreliable block, less patient satisfaction, and a significant failure rate.[5]

Anesthetic concerns mainly focused on avoiding the increase in systemic and pulmonary vascular resistance, maintaining the systemic ventricular function, and avoiding air entry into the circulation to prevent paradoxical air embolism. The use of a lower dose of local anesthetic with sequentially combined spinal-epidural; using saline for loss of resistance technique, and strict perioperative vigilance helped us achieve that goal in this patient, and we concur that it might be a good option in parturients with CC-TGA.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Arendt KW, Connolly HM, Warnes CA, Watson WJ, Hebl JR, Craigo PA. Anesthetic management of parturients with congenitally corrected transposition of the great arteries: Three cases and a review of the literature. Anesth Analg 2008;107:1973-7.  Back to cited text no. 1
Gulati G, Das B, Mangla A. Congenitally corrected TGA-A case diagnosed incidentally. Asian Pac J Health Sci 2015;2:56-8.  Back to cited text no. 2
Ajmera P, Medep V. A case of congenitally corrected transposition of great arteries: An infrequent happenstance. Case Rep Med 2017;2017:7565870.  Back to cited text no. 3
Connolly HM, Grogan M, Warnes CA. Pregnancy among women with congenitally corrected transposition of great arteries. J Am Coll Cardiol 1999;33:1692-5.  Back to cited text no. 4
Tawfik MM, Hafez H, Abdelkhalek M, Allakkany NS. Combined spinal-epidural anesthesia for cesarean section in a parturient with congenitally corrected transposition of the great arteries. J Anaesthesiol Clin Pharmacol 2017;33:418-20.  Back to cited text no. 5
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