Peripartum cardiomyopathy (PPCM), a dilated cardiomyopathy (DCM) presenting between 3rd trimester and 5 months postpartum, is a diagnosis of exclusion characterized by <45% ejection fraction (EF) and dilated left ventricle.1 Presenting symptoms are fatigue, dyspnea and leg swelling, with increased risk for arrhythmias, thromboembolic events and sudden cardiac death.
Case report
Now 43 years old, a G1P1 woman with pregestational HTN was diagnosed with PPCM 3 months after an uncomplicated vaginal delivery (2004). Worsening postpartum dyspnea had prompted a cardiac ECHO showing global DCM with 35% EF; metoprolol, aspirin and furosemide were started. She developed tricuspid regurgitation (2005), atrial fibrillation (2010), received an automatic implantable cardioverter-defibrillator for 15% EF (2012), and had a DVT (2015). Pulmonary hypertension (pHTN; peak systolic 47mmHg) was diagnosed in 2017, and she was placed on heart transplant waiting list and referred for left ventricular assist device (LVAD). A pre-LVAD ECHO showed 6% EF (Fig.) and CI on catheterization was 0.93 L/min/m2. We report here the anesthetic management for LVAD placement and tricuspid annuloplasty under cardiopulmonary bypass (17/10/2017). Pre-induction management included an arterial line, with vasopressors infusions (milrinone, epinephrine, dobutamine). After GA induction, a pulmonary arterial catheter was placed, and inhaled NO was started (20ppm). Chest closure occurred 36h after ICU admission and extubation at 48h. She was discharged on postop day 12 on bumetanide, sildenafil, warfarin and aspirin, and is still awaiting heart transplant.
Discussion
Long term follow-up of women with PPCM shows recovery in 50% of cases, with 25% stable on medication and 25% progressing into severe heart failure, as was the case here. Risk factors here for PPCM included African American descent and HTN. Presenting symptoms where shortness of breath during pregnancy, which culminated 3 months postpartum. Over the course of 13 years, she developed severe DCM, tricuspid regurgitation and a DVT. Perioperative management highlights judicious management of extreme heart failure (EF 6%) & moderate pHTN, using a wide array of inotropic drugs, followed by anticoagulation. Literature long term follow-up in women with PPCM is scarce, and there have only been few reports of women receiving LVAD, usually in the immediate postpartum period, with mixed outcomes.

11 / Long Term Outcomes of a Patient with Severe Peripartum Cardiomyopathy Following an Uncomplicated Vaginal Delivery