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Review
Article Pregnancy and non-valvular heart
disease – Anesthetic considerations
Gaurab Maitra, Saikat Sengupta, Amitava Rudra1, Saurabh Debnath2
Consultant Anaesthesiologist, 1Hon. Consultant Anesthesiologist and 2PG student in Anesthesiology, Department of
anesthesiology, Apollo Gleneagles Hospital, Kolkata, India

ABSTRACT Non-valvular heart disease is an important cause of cardiac disease in pregnancy and presents a unique
challenge to the anesthesiologist during labor and delivery. A keen understanding of the underlying
pathophysiology, in addition to the altered physiology of pregnancy, is the key to managing such patients.
Disease-specific goals of management may help preserve the hemodynamic and ventilatory parameters
within an acceptable limit and a successful conduct of labor and postpartum period..
Received: 14-07-09
Accepted: 27-11-09 Key words: Pregnancy, non-valvular heart disease, anesthesia, labor

DOI: 10.4103/0971-9784.62933

INTRODUCTION improve both maternal and fetal outcome.[5]

The prevalence of cardiac disease in pregnancy
has remained relatively constant over the past
decades and ranges from 0.4-4.1%.[1-3] In the
developed world, congenital heart disease has
supplanted rheumatic heart disease as the
major cause of cardiac disease in pregnancy
because, with the improvement in outcome
in surgery for congenital heart anomalies,
patients are increasingly likely to survive
up to the child-bearing age.[4] Counseling of
women with cardiac diseases is best performed
prior to conception. This will allow for a
thorough history taking and evaluation that
includes invasive procedures like cardiac
catheterization with fluoroscopy, if needed.
These procedures are better performed during
non-pregnant state to avoid potential fetal risks.
However, majority of the cardiac diseases,
whether acquired or congenital, can now be
evaluated non-invasively by transthoracic
echocardiography; cardiac catheterization
is reserved for a few patients in whom
corrective intracardiac repair is planned and
adequate information could not be obtained
by echocardiographic imaging. In addition,
patients with surgically correctable lesions
should undergo repair before pregnancy to
This article deals with only the non-valvular
heart disease in pregnancy and anesthetic
considerations in the peri-partum period.
PHYSIOLOGICAL AND GENERAL CONSIDERATIONS
There are five physiological changes which
occur during pregnancy and they represent
unique problems with anesthetic implications
in patients with cardiac diseases:
i) Fifty per cent increase in intravascular
volume that peaks by early to mid third
trimester
ii) Progressive decrease in systemic vascular
resistance throughout pregnancy such that
the mean arterial pressure is preserved at
normal values despite 30-40 % increase in
cardiac output. There is 15 % increase in
heart rate.
iii) Marked fluctuations in cardiac output
during labor with tachycardia and about
500 ml of blood added to the circulation
during each uterine contraction.
iv) Hyper coagulability associated with
pregnancy.
v) Reduced functional residual capacity[6]
The most common causes of maternal death-

Address for correspondence: Dr. Saurabh Debnath, 2A, Nutan Path, Modern Park, Santoshpur, Kolkata 700075 Kolkata India, E- mail: saurabhdebnath00@
yahoo.com

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Maitra, et al.: Pregnancy and non-valvular heart disease
embolism and hemorrhage, have remained unchanged
over the past decades, but there has been an increase
in maternal mortality from cardiac causes.[7] Due to
reduced cardiopulmonary reserve in pregnancy, women
with cardiovascular disease have an increased rate of
abortion and a higher incidence of small for gestation
age children.[8]
Predictors for cardiovascular complications during
pregnancy include:
• Earlier cardiovascular events or arrhythmias
(cardiac decompensation, stroke, transient ischemic
attack)
• Heart failure with New York Heart Association
(NYHA) classification of more than 2 or cyanosis
• Ejection fraction less than 40% [ 9 ]
GROWN UP WITH CONGENITAL HEART DISEASE (GUCH)
Congenital heart disease is now the major cause of
cardiac disease in pregnant women in the United States,
accounting for 60-80 % of all cases. In some cases,
successful surgery during infancy and childhood results
in complete repair and normal cardiovascular function.
Such patients often require no special treatment apart
from two considerations. First, antibiotic prophylaxis
may be warranted as per the current recommendations.
Second, the presence of neonatologist at delivery is
desirable as there is 0.7-1 % incidence of congenital
cardiac lesions in the offspring of these women. On
the other hand, some women may present during
pregnancy with uncorrected lesion or partially corrected
lesion, which becomes an anesthetic challenge during
the conduct of labor. [10] Sometimes, parturients,
especially in the non urban areas land up in less than
ideal hospitals for management of labor and delivery.
Therefore obtaining a detailed history and conducting a
meticulous exam of the patient is vital. Patients detected
with such cardiac disease should be referred to higher
centers with adequate monitoring facilities and trained
personnel for peripartum and perinatal care. Both
maternal and fetal monitoring is essential throughout
the peripartum period.
i) Left to Right shunts — Either small atrial septal
defects (ASD) or ventricular septal defects (VSD) or
patent ductus arteriosus (PDA) with modest left to
right shunt is often well tolerated during pregnancy.
During the peri-operative period, care should be
taken to avoid accidental intravenous infusion of air
bubbles. During epidural space localization loss of
resistance to saline rather than air is preferable as
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identification of the epidural space with air might
result in systemic air embolization. Even small
amount of air can result in systemic embolization
due to transient reversal of pressures in left or right
side of heart during the cardiac cycle. Early epidural
analgesia is desirable to avoid pain and resulting
increase in systemic vascular resistance (SVR) and
therefore potential left to right shunt. Intrapartum
monitoring of mother with trans-esophageal
echocardiography is beneficial. Slow onset epidural
anesthesia is preferred as rapid decrease in SVR
could possibly result in reversal of shunt flow and
hypoxemia. And finally, the patient may benefit
from supplemental inspired oxygen which may
decrease the chance of patient developing hypoxia
caused by reversal of shunt due to elevation of
pulmonary vascular resistance.[ 11]
Anesthetic goals
• avoid accidental injection of air intravenously
• avoid decrease in SVR
• prevent hypoxia, hypercapnia, acidosis
ii) Coarctation of Aorta — Coarctation of aorta is
characterized by narrowing of the aorta at or
near the insertion of ductus arteriosus. Maternal
hypertension, particularly of the upper body is the
principal concern.[12,13] An arm to leg systolic blood
pressure gradient of less than 20 mm Hg is associated
with a good outcome during pregnancy.[14] Pregnant
women with uncorrected coarctation or a residual
decrease in aorta diameter are at high risk for left
ventricular failure, aortic rupture or dissection. In
such pregnancies, fetal mortality rate may reach
up to 20 % because of decreased uterine perfusion
distal to the aorta lesion.[15] Controlling maternal
hypertension is important to diminish the chances
of aortic dissection and rupture and beta blockers are
indicated to achieve these. Although administration
of beta blockers during pregnancy may increase the
chance of fetal growth retardation, maternal safety
takes precedence. The anesthetic management is
aimed towards maintaining normal (or slightly
elevated) SVR and heart rate, while taking care
to keep the intravascular volume adequate. For
caesarean section, general anesthesia is preferred
though slow onset (“graded”) epidural anesthesia
has also been used.
Physiologically, an uncorrected coarctation of aorta
represents a fixed obstruction to aortic outflow
with distal hypoperfusion. The use of regional
block in the presence of a fixed cardiac output
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Maitra, et al.: Pregnancy and non-valvular heart disease
state is controversial, because of the potential risk
of excessive fall in SVR and reduction in venous
return. Maintaining a maternal lower limb systolic
blood pressure at more than100 mmHg is advisable,
in order to avoid compromising the placental
blood flow. Continuous fetal heart rate monitoring
should be maintained during anesthesia to detect
any compromise in placental circulation. As per
current recommendations antibiotic prophylaxis for
endocarditis and endoarteritis is recommended.[12]
Invasive hemodynamic monitoring can help guide
the administration of intravenous fluids. Uterine
perfusion is reflected by using a post-ductal intra-
arterial catheter instead of a pre-ductal catheter.
Fetal bradycardia can also indicate placental hypo
perfusion but only after a time lag. Ephedrine and
dopamine are vasopressors of choice for their mild
positive chronotropic effect.[11]
Anesthetic goals
• maintain normal to slightly elevated SVR
• maintain normal to slightly elevated heart rate
• maintain adequate intravascular volume and
venous return
• invasive hemodynamic monitoring
iii ) Tetralogy of Fallot — Accounts for 5 % of cases of
congenital heart disease in pregnancy. Includes four
components –
• A ventricular septal defect (VSD)
• Infundibular or right ventricular outflow tract
obstruction
• Overriding of aorta sitting over the VSD
• Right ventricular hypertrophy
It is the commonest congenital heart disease with right
to left shunt. Patients present with cyanosis. Pregnant
women with tetralogy usually have had corrective
surgery in childhood – closure of VSD and widening
of pulmonary outflow tract. In some, a small residual
VSD may be present or progressive hypertrophy
of pulmonary outflow tract may occur slowly over
decades.
In these patients the physiological stress and
compromised cardiopulmonary function of the
pregnant state combined with the effect of residual
cardiovascular lesions after corrective surgery is of
concern because of –
• Progressive right ventricular dysfunction
• Atrial and ventricular dysrhythmia
• Thromboembolic phenomena
• Progressive aortic root dilatation
104
• Intrauterine growth retardation
• Endocarditis[16]
Patients with corrected tetralogy, even if asymptomatic
for many years, should undergo echocardiography
before and during early pregnancy. These patients
may manifest atrial and ventricular arrhythmias due to
surgical injury to cardiac conduction system. A 12 lead
electrocardiogram (ECG) and ECG monitoring during
labor is desirable. Meticulous attention should be given
to avoid any intravenous air bubble infusion as it may
lead to systemic embolization.
In uncorrected TOF or corrected TOF with residual
disease, anesthetic management revolves around
avoiding decrease in SVR, which increases right to left
shunt. It is important to maintain intravascular volume
and venous return. Trans-esophageal echocardiographic
monitoring is helpful. Administration of epidural
block recommended in early labor to avoid pain and
consequent right ventricular outflow tract spasm and
increase in right to left shunt. For caesarean section
onset of regional block should be slow so single shot
spinal is a poor choice as abrupt decrease in SVR may
cause increase in right to left shunt.[11]
Antibiotic prophylaxis against endocarditis is essential.
Anesthetic goals
• Avoid decrease in SVR
• Maintain adequate intravascular volume and venous
return
• Epidural analgesia early in labor
Eisenmenger’s Syndrome — This is a consequence
of chronic uncorrected left to right shunt producing
right ventricular hypertrophy, elevated pulmonary
artery pressure and right ventricular dysfunction.
Primary lesion may either be ASD, VSD or PDA. A
reversal of shunt occurs when pulmonary arterial
pressure exceeds systemic pressure and ultimately
irreversible pulmonary hypertension occurs, at which
point correction of primary lesion is not helpful. It
presents with arterial hypoxemia and right ventricular
failure. Pregnancy-associated decrease in SVR increases
severity of right to left shunt with decreased pulmonary
perfusion. Decrease in functional residual capacity
further predisposes to hypoxemia.[11] In the presence
of fixed pulmonary hypertension, reduction in right
ventricular filling pressure due to hypotension from
any cause may lead to sudden profound hypoxemia and
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Maitra, et al.: Pregnancy and non-valvular heart disease
death. Maternal hypoxemia results in decreased oxygen
delivery to fetus and thus high incidence of intra-uterine
growth retardation (IUGR) and fetal demise.[17] Maternal
mortality is as high as 30-50 % in these patients.[18]
Patients with Eisenmenger’s syndrome who become
pregnant should be consulted to terminate pregnancy.[19]
For a patient who continues her pregnancy,
hospitalization for the duration of pregnancy is often
appropriate. Continuous administration of oxygen,
the pulmonary vasodilator of choice, is mandatory.
Maternal arterial partial pressure of oxygen should
be maintained at a level of 70 mmHg or above. Fetal
outcome correlates well with maternal hematocrit and
successful pregnancy is unlikely with a hematocrit
>65%. [20] Thromboembolic phenomenon cause
about 43% of the maternal deaths and prophylactic
anticoagulation is favoured by some.[21]
The primary goals of anesthetic management are as
follows:
• maintain adequate SVR
• maintain intravascular volume and venous return,
avoid aorto-caval compression
• prevent pain, hypoxemia, hypercarbia, acidosis
• avoid myocardial depression during general
anesthesia[22-24]
Supplemental oxygen should be provided at all times
during labor and pulse oxymeter is the most useful
monitor for detecting acute changes in shunt flow.[25]
An intra arterial catheter facilitates rapid detection of
sudden changes in blood pressure and central venous
pressure catheter can help reveal significant changes
in cardiac filling pressures.
A pulmonary artery catheter may be relatively
contraindicated for several reasons.[23,26] First, it is
difficult to position the balloon-tipped, flow directed
catheter within pulmonary artery. Second, the risks of
pulmonary artery rupture are great. Third, these patients
may not tolerate catheter-induced arrhythmias. Fourth,
measurement of cardiac output by thermo-dilution is
unpredictable in the presence of large intra-cardiac
shunt. And pulmonary artery pressure monitoring
rarely yields useful clinical information in severe fixed
pulmonary hypertension scenario. Trans-esophageal
echocardiography may be a useful monitor instead.
For providing effective labor analgesia, intrathecal
opioid administration is ideal in first stage of labor. For
second stage epidural or intra-thecal local anesthetic or
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opioid or pudendal block provides satisfactory analgesia.
Where maternal anticoagulation may contraindicate
regional techniques, intravenous remifentanil infusion
with or without patient controlled analgesia (PCA)
is another option.[27] For elective caesarean section,
favorable outcomes have been achieved with slow
onset epidural anesthesia, which has become the
technique of choice for parturients with Eisenmenger’s
syndrome.[24,28] It is critical that anesthesiologists avoid
aorto-caval compression and maintain adequate venous
return. Intravenous crystalloid and small doses of
phenylephrine are administered as needed to maintain
preload, SVR and oxygen saturation.
There are several disadvantages with the use of
general anesthesia – positive pressure ventilation
causes decreased venous return, volatile agents cause
myocardial depression and decrease SVR, rapid
sequence induction with thiopentone or propofol
decreases both contractility and SVR. All of these
exacerbate the right to left shunt.[11] Moreover, the right
to left shunt will also influence anesthetic induction
as inhalational induction will be prolonged and
intravenous induction might be hastened as these agents
can bypass the lungs.[29] There is a risk of postoperative
atelectasis following general anesthesia, which can
worsen right to left shunt.
Successful delivery may be enhanced by means of
improved oxygenation with inhaled nitric oxide for
patients with pulmonary hypertension and hypoxymia.[30]
Primary Pulmonary Hypertension (PPH) — Syndrome of
PPH is characterized by markedly elevated pulmonary
artery pressure in the absence of an intra-cardiac or
aorto-pulmonary shunt.[31] Pulmonary hypertension
is tolerated poorly in the parturient. Deterioration
typically occurs in the second trimester with symptoms
of fatigue, dyspnea, syncope and chest pain. This is due
to the physiological increase in cardiac output and blood
volume by 40-50%. During labor, uterine contractions
effectively add 500 ml of blood to the circulation. The
pain and expulsive effort of labor increase right atrial
pressure, blood pressure and cardiac output. Women
with PPH are advised against pregnancy. In early
pregnancy a termination is considered. Where PPH
is not diagnosed until late in pregnancy an elective
delivery at 32-34 weeks gestation is preferred, as
premature spontaneous labor is common.[32] Unlike
those with Eisenmenger’s syndrome, patients with PPH
often have a reactive pulmonary vasculature that can
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Maitra, et al.: Pregnancy and non-valvular heart disease
respond to vasodilator therapy. The maternal mortality
may be as high as 30-40 % with a high incidence of
IUGR, preterm delivery and fetal loss.[33] The goals
of anesthetic management are similar to those of
Eisenmenger’s syndrome. Supplemental oxygen – a
good pulmonary vasodilator, should be administered
routinely. Intra-arterial blood pressure and central
venous pressure monitoring is needed. Pulmonary
artery catheterization carries risks. The benefits do
not outweigh the risks in these groups of patients.
Trans-esophageal echocardiography has been used
intra-operatively during caesarean delivery.[34] Agents
that have been used to treat PPH include inhaled nitric
oxide (iNO), nitroglycerin, calcium entry blockers and
prostaglandins.[35-37] Patients with PPH are at risk of
thrombosis and thrombo-embolism. The Mayo Clinic
group has reported that anticoagulation may improve
the outcome in severe pulmonary hypertension.[31]
Epidural anesthesia allows for a pain-free first and
second stage of labor and facilitates elective forceps
delivery. Several reports have noted the successful
use of epidural anesthesia for caesarean section.[38, 39]
Slow induction of epidural anesthesia is important.
Hypotension should be treated with intravenous
fluids and ephedrine should be avoided as it can
increase pulmonary artery pressure. For cases where
regional anesthesia is contraindicated (concurrent
anticoagulant therapy), intravenous dexmedetomidine
has been shown to be beneficial as an adjunct to general
anesthesia for providing pain relief and hemodynamic
stability.[40]
Anesthetic goals are:
• Supplemental oxygen
• Invasive hemodynamic monitoring, avoid
pulmonary artery catheter
• Treat pulmonary hypertension
• Slow induction of epidural anesthesia
• Treat hypotension with fluids, avoid ephedrine
Peripartum Cardiomyopathy (PPCM) — It is defined as
a devastating form of heart failure with onset during
the last months of pregnancy or during the first five
months postpartum.[41] The incidence is 1 in 3000 to
4000 live births.[42] The etiology is unknown. Viral,
auto-immune and toxic factors have been implicated.
[43]
It remains unclear whether PPCM represents a
unique syndrome or a pregnancy related exacerbation
of some other form of cardiomyopathy. Approximately
50 % of women will have complete or near complete
recovery of ventricular function. The remaining
106
women will undergo progressive clinical deterioration
resulting in cardiac transplantation or early death.[44]
Obstetric management involves expedient delivery of
the fetus by caesarean or instrumental vaginal delivery.
Anticoagulation is indicated as PPCM increases the risk
of thromboembolism.[45] General anesthesia may result
in profound myocardial depression.[46] Use of regional
anesthesia (slow induction of epidural anesthesia
guided by pulmonary artery pressure measurements)
has been reported.[47] Regional anesthesia can be used
safely except for those with most severe cardiovascular
compromise and the timing of administration used
for thromboprophylaxis may prevent it’s use in some
cases.[ 48] Intrapartum monitoring with trans-esophageal
echocardiography is beneficial.
Anesthetic goals
• Avoid general anesthesia if possible
• Slow induction of epidural anesthesia is better
• Pulmonary artery pressure monitoring
• Reduction of preload and afterload
Hypertrophic Obstructive Cardiomyopathy (HOCM)
— It is an unknown form of cardiomyopathy that
affects the interventricular septum in the area of left
ventricular outflow tract.[49] Women with HOCM have an
increased risk of maternal mortality and sudden death.
[50]
The prevalence of HOCM is 1 in 500 to 1 in 1000.
The physiological alterations of pregnancy augment or
reveal the symptoms of HOCM like chest pain, dyspnea
and palpitations. Impaired diastolic filling results in
raised left ventricular end-diastolic, left atrial and
pulmonary wedge pressures. The diagnosis of HOCM is
made by echocardiography demonstrating unexplained
asymmetrical myocardial hypertrophy with maximal
wall thickness >2 standard deviations for age. In less
than half the women, the condition is diagnosed before
the first pregnancy. There is a much lower mortality
than with PPCM, and the majority of women have a
good outcome. Medical management includes treatment
with a beta adrenergic receptor antagonist which should
be continued during pregnancy. Beta adrenergic block
reduces contractility and heart rate, thereby increasing
diastolic filling time and improving ventricular filling.
[51]
Vasodilatation and hypotension are avoided as it
reduces the venous return and ventricular filling. If
vasopressors are required, a pure alpha receptor agonist
is preferred to vasoconstrictors with ionotropic action[52]
Trans-esophageal echocardiography may be helpful.
Women of child bearing age who are symptomatic or
have a history of syncope or pre-syncope should be
considered candidates for insertion of a pacemaker
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Maitra, et al.: Pregnancy and non-valvular heart disease
or an automatic implantable cardioverter defibrillator
(AICD) before conception.[53]
The goals of anesthetic management are to:[22,54-56]
• maintain intravascular volume and venous return,
avoid aorto-caval compression
• maintain adequate SVR
• maintain slow heart rate and sinus rhythm,
aggressively treat atrial fibrillation and other tachy-
arrhythmias
• prevent increase in myocardial contractility
An elective caesarean delivery may be performed safely
with epidural anesthesia.[54] HOCM represents a relative
contraindication to single shot spinal anesthesia for
caesarean section as the rapid onset sympathectomy is
hazardous. During general anesthesia volatile agents
decrease myocardial contractility which is advantageous
in these patients and remains the preferred choice. The
most common adverse occurrence following general
anesthesia in these patients is reversible congestive
heart failure.[56]
Ischemic Heart Disease — Myocardial infarction,
fortunately is a rare event during pregnancy. However,
the incidence of myocardial ischemia during pregnancy
may be increasing for several reasons. First, there is a
greater prevalence of delayed childbearing. Second,
many young women continue to abuse tobacco. Third,
there is an increased incidence of cocaine abuse by
women of child bearing age. Finally, the use of oral
contraceptives after 35 years of age may increase the
risk of ischemic heart disease.[11]
Medical management of the pregnant women with
coronary artery disease requires attention to other
disease states (anemia, thyrotoxicosis, hypertension,
infection, substance abuse) that may adversely affect
myocardial oxygen supply and demand. [57] The
pharmacological agents, nitrates, beta adrenergic
receptor antagonists, calcium entry antagonists used
in treatment of myocardial ischemia in non-pregnant
patients are also used during pregnancy with attention
to both mother and fetus.
Amongst antiplatelet agents, clopidogrel is avoided
in pregnancy for safety issues but low dose aspirin
can be used without any contraindication for regional
anesthetic technique that may be employed for labor
analgesia or caesarean delivery, provided the platelet
count is more than 80,000 mm-3 and bleeding time is
normal.[58] Most patients with severe cardiac diseases
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in pregnancy can be managed medically. Ischemia that
is unresponsive to medical management may require
percutaneous transluminal coronary angioplasty
(PTCA)[59] or coronary artery bypass surgery (CABG).[60]
In order to reduce fetal radiation exposure from
fluoroscopy, guidance by means of transesophageal
echocardiography may be used. Maternal and fetal
mortality rates with interventional procedures are
low. Pregnancy appears to increase the mortality risk
associated with cardiac surgery.[61] No consensus exists
regarding the optimal method of delivery in these
patients. It seems reasonable to reserve caesarean
section for obstetric indications unless maternal
hemodynamic instability mandates immediate
delivery. The ECG and SpO2 should be monitored
continuously during labor and vaginal or caesarean
delivery. Supplemental oxygen should be administered
during labor and delivery. Epidural anesthesia
provides excellent pain relief and reduces maternal
concentrations of catecholamines and thus chance of
coronary artery vasoconstriction. Phenylephrine is the
preferred vasopressor for treatment of hypotension in
these patients as ephedrine increase maternal heart
rate, increase myocardial oxygen demand and aggravate
myocardial ischemia. When general anesthesia is given,
a modified rapid sequence induction (using etomidate,
remifentanil and succinylcholine) can be performed
over one or two minutes without compromising
hemodynamics. Single shot spinal anesthesia results
in rapid onset of sympathectomy and increased risk of
severe hypotension.[11] Continuous epidural anesthesia
is the preferred technique for cesarean section.[62, 63]
General anesthesia is to be considered only when
regional anesthesia is contraindicated (concurrent use
of anticoagulant or when antiplatelet drug can’t be
stopped as in case of recent coronary stent placement).
Bolus dose oxytocin is to be avoided, as it can cause
profound vasodilatation and compensatory tachycardia
resulting in reduced coronary diastolic filling. It
may be administered as 5-10 units in 100 milliliters
saline over five minutes followed by 20 units in 500
milliliters saline over four hours, reducing the rate if
heart rate increases. Last but not the least, fetal heart
rate monitoring should be continued throughout the
peripartum period[64].
Anesthetic goals
• to monitor SpO2 and ECG continuously
• phenylephrine is the preferred vasopressor
• avoid hypotension
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CONCLUSION
A comprehensive understanding of the physiology
of pregnancy and pathophysiology of maternal
cardiac disease is of importance for anesthesiologists,
gynecologists and cardiologists involved in peri-partum
care in patients with maternal cardiac disease. A careful
consideration of maternal and fetal risks is imminent
for the decision about which mode of delivery and peri-
partum analgesia and anesthesia management should
be chosen.
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Cite this article as: Maitra G, Sengupta S, Rudra A, Debnath S. Pregnancy
and non-valvular heart disease – Anaesthetic considerations. Ann Card
Anaesth 2010;13:102-9.
Source of Support: Nil, Conflict of Interest: None declared.
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