Anesthetic management of peripartum cardiomyopathy

INTRODUCTION: Peripartum cardiomyopathy (PPCM) is a rare idiopathic cardiomyopathy frequently presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery. Within the published literature, there are case reports extolling the safety of both regional and general anesthetic interventions in PPCM. However, there is an absence of high-quality evidence to define a suitable paradigm for peri-operative care. In the absence of a large prospective case series or clinical trials, the synthesis of clinical data from published case reports provides an opportunity to distil published clinical data and explore the effect of clinical interventions. EVIDENCE ACQUISITION: A systematic search of English articles English language case reports published between 1986 and 2020 within multiple databases. Clinical data was extracted and aggregated into a database for analysis. EVIDENCE SYNTHESIS: Gestational hypertension and pre-eclampsia were pre-partum risk factors. 403 case reports provided 466 individual cases from 48 countries. Neither regional nor general anesthetic interventions in the peripartum period have a discernible impact on the outcome of patients with PPCM. Rapid unpredictable deterioration in the peripartum period, requiring mechanical cardiac support or heart transplantation is described. The mortality of PPCM is 5-6%. CONCLUSIONS: Patients with PPCM are at risk of rapid unpredictable decline. Management within specialist centers should be considered. Although the data is unsuitable to provide a comprehensive paradigm for the anesthetic and critical care management of PPCM, the observations provide a direction for future clinical audits and trials.