General Anesthesia for Emergent Cesarean Delivery in a Parturient with Severe Left Ventricular Dysfunction: A Case Report with a Multidisciplinary, Rescue-Oriented Strategy

Background: Severe left ventricular dysfunction during pregnancy carries extreme maternal and fetal risk. Anesthetic management becomes challenging when rapid clinical deterioration coincides with an urgent need for therapeutic anticoagulation. Case Presentation: A 36-year-old woman at 32 weeks and 3 days of gestation with New York Heart Association class IV heart failure, atrial fibrillation with rapid ventricular response, and an ejection fraction of 25% underwent emergent cesarean delivery for rapidly worsening cardiac decompensation. Given severe ventricular dysfunction, persistent tachyarrhythmia, and anticipated immediate postoperative therapeutic anticoagulation, neuraxial anesthesia was deemed unsafe despite institutional preference for epidural techniques in cardiac parturients. A multidisciplinary team involving obstetrics, cardiology, anesthesiology, and cardiothoracic surgery established a rescue-oriented perioperative strategy. Femoral arterial guidewire placement was performed preemptively to facilitate rapid extracorporeal membrane oxygenation (ECMO) cannulation if required, and the cardiothoracic surgeon remained on standby throughout delivery. General anesthesia was administered with invasive monitoring. Intraoperative transesophageal echocardiography guided management and informed the decision to perform synchronized cardioversion for refractory atrial fibrillation; ECMO was not required. Left ventricular function improved from 25% preoperatively to 52% by postoperative day 4. Conclusion: Near-catastrophic obstetric cardiac cases benefit from structured risk stratification, anticoagulation-informed anesthetic selection, real-time echocardiographic decision support, and predefined multidisciplinary rescue pathways, including readiness for mechanical circulatory support.