Peripartum cardiomyopathy

[Peripartum cardiomyopathy: incidence, pathogenesis, diagnosis, treatment and prognosis]

INTRODUCTION

Peripartum cardiomyopathy (PPCM) is a rare and life-threatening disease of unknown aetiology. The primary objective of this review was to analysed aetiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis of this pathology.

METHODS

We undertook a systematic review of the literature using Medline, Google Scholar and PubMed searches.

RESULTS

Unlike other parts of the world in which cardiomyopathy are rare, dilated cardiomyopathy is a major cause of heart failure throughout Africa. Its aetiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. This diagnosis should be limited to previously healthy women who present with congestive heart failure (CHF) and decreased left ventricular systolic function in the last month of pregnancy or within 5 months after delivery. Recently, introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Conventional treatment consists of diuretics, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. Patients who fail to recover may require inotropic therapy. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover normal heart function.

CONCLUSION

PPCM is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Its aetiopathogenesis is still poorly understood. Introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Prognosis is highly related to reversal of ventricular dysfunction.

A serious complication in the puerperium: peripartum cardiomyopathy

Two women, aged 27, presented with different symptoms shortly after giving birth to their first child. Peripartum cardiomyopathy (PPCM) was diagnosed. PPCM is a rare form of cardiac failure occurring late in pregnancy or in the postpartum period. Many women experience dyspnoea, fatigue, and pedal oedema in the last month of pregnancy or postpartum, symptoms which are identical to early congestive heart failure. Therefore, the diagnosis of PPCM requires vigilance. A high mortality rate and overall poor clinical outcome has been reported in a high percentage of these patients. Subsequent pregnancies remain controversial. (Neth Heart J 2008;16:415-8.).

Aetiology and risk factors of peripartum cardiomyopathy: a systematic review

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a disorder of unknown aetiology in which heart failure due to left ventricular dysfunction occurs between the last month of pregnancy and first five months post-partum. Theories abound concerning the specific cause and risk factors for PPCM, but none have been accepted universally. The primary objective of this review was to summarize the state of knowledge on the pathogenesis of PPCM, especially in light of recent studies.

METHODS

We searched MEDLINE (January 1966-September 2007), OVID, and reference lists of articles for studies containing information on the aetiology and risk factors for PPCM, and published in English.

RESULTS

The literature reveals a wealth of articles proposing various mechanisms for aetiology and risk factors of PPCM. There is conflicting evidence on the pathogenetic role of viral myocarditis, abnormal immune response to pregnancy, abnormal response to the haemodynamic stress of pregnancy, accelerated myocyte apoptosis, cytokine-induced inflammation, malnutrition, genetic factors, excessive prolactin production, abnormal hormonal function, increased adrenergic tone, and myocardial ischaemia. A number of factors are postulated to increase the risk of the development of PPCM. These include non-Caucasian ethnicity, advanced maternal age, multiparity, poor socioeconomic status, multiple pregnancy and prolonged tocolytic use. The authors call for a strict definition of PPCM that excludes known causes of heart failure, such as the pregnancy-induced hypertensive spectrum of disorders.

CONCLUSION

The aetiology and risk factors for PPCM are poorly defined. There is a need for large-scale multi-centre epidemiological studies and registries to delineate the aetiology and pathogenesis of PPCM.

Characterisation of peripartum cardiomyopathy by cardiac magnetic resonance imaging

Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure. Only half of the patients recover normal cardiac function. We assessed the usefulness of magnetic resonance imaging (MRI) and late enhancement imaging to detect myocardial fibrosis in order to predict cardiac function recovery in patients with peripartum cardiomyopathy. Among a consecutive series of 1,037 patients referred for heart failure treatment or prognostic evaluation between 1999 and 2006, eight women had confirmed PPCM. They all underwent echocardiography and cardiac MRI for assessment of left ventricular anatomy, systolic function and detection of myocardial fibrosis through late enhancement imaging. Mean (+/- SD) baseline left ventricular ejection fraction (LVEF) was 28 +/- 4%. After a follow-up of 50 +/- 9 months, half the patients recovered normal cardiac function (LVEF = 58 +/- 4%) and four did not (LVEF = 35 +/- 6%). None of the eight patients exhibited abnormal myocardial late enhancement. No difference in MRI characteristics was observed between the two groups. Patients with PPCM do not exhibit a specific cardiac MRI pattern and particularly no myocardial late enhancement. It suggests that myocardial fibrosis does not play a major role in the limitation of cardiac function recovery after PPCM.

Peripartum cardiomyopathy: review of the literature

Peripartum cardiomyopathy (PPCM) is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Clinical presentation of PPCM is similar to that of systolic heart failure from any cause, and it can sometimes be complicated by a high incidence of thromboembolism. Prior to the availability of echocardiography, diagnosis was based only on clinical findings. Recently, inclusion of echocardiography has made diagnosis of PPCM easier and more accurate. Its etiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. Prompt recognition with institution of intensive treatment by a multidisciplinary team is a prerequisite for improved outcome. Conventional treatment consists of diuretics, beta blockers, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Cardiac transplantation may be necessary in patients not responding to conventional and newer therapeutic strategies. The role of the anesthesiologist is important in perioperative and intensive care management. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover heart function. This article aims to provide a comprehensive updated review of PPCM covering etiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis, while stressing areas that require further research.

An unusual case of peripartum cardiomyopathy manifesting with multiple thrombo-embolic phenomena

Peripartum cardiomyopathy (PPCM) is a rare form of heart failure with a reported incidence of 1 per 3000 to 1 per 4000 live births and a fatality rate of 20%–50%. Onset is usually between the last month of pregnancy and up to 5 months postpartum in previously healthy women. Although viral, autoimmune and idiopathic factors may be contributory, its etiology remains unknown. PPCM initially presents with signs and symptoms of congestive heart failure and rarely with thrombo-embolic complications. We report an unusual case of PPCM in a previously healthy postpartum woman who presented with an acute abdomen due to unrecognized thromboemboli of the abdominal organs. This case illustrates that abdominal pain in PPCM may not always result from hepatic congestion as previously reported, but may occur as a result of thromboemboli to abdominal organs. Further research is needed to determine the true incidence of thromboemboli in PPCM.

Pregnancy: Maternal and Fetal Heart Disease

Cardiac disorders complicate less than 1% of all pregnancies. Physiologic changes in pregnancy may mimic heart disease. In order to differentiate these adaptations from pathologic conditions, an in-depth knowledge of cardiovascular physiology is mandatory. A comprehensive history, physical examination, electrocardiogram, chest radiograph, and echocardiogram are sufficient in most cases to confirm the diagnosis. Care of women with cardiac disease begins with preconception counseling. Severe lesions should be taken care of prior to contemplating pregnancy. Management principles for pregnant women are similar to those for the non-pregnant state. A team approach comprised of a maternal fetal medicine specialist, cardiologist, neonatologist, and anesthesiologist is essential to assure optimal outcome for both the mother and the fetus. Although fetal heart disease complicates only a small percentage of pregnancies, congenital heart disease causes more neonatal morbidity and mortality than any other congenital malformation. Unfortunately, screening approaches for fetal heart disease continue to miss a large percentage of cases. This weakness in fetal screening has important clinical implications, because the prenatal detection and diagnosis of congenital heart disease may improve the outcome for many of these fetal patients. In fact, simply the detection of major heart disease prenatally can improve neonatal outcome by avoiding discharge to home of neonates with ductal-dependent congenital heart disease. Fortunately, recent advances in screening techniques, an increased ability to change the prenatal natural history of many forms of fetal heart disease, and an increasing recognition of the importance of a multidisciplinary, team approach to the management of pregnancies complicated with fetal heart disease, together promise to improve the outcome of the fetus with congenital heart disease.

Incidence, mortality, and racial differences in peripartum cardiomyopathy

There are no large population-based studies on the incidence and prognosis of peripartum cardiomyopathy (PC). Between 1996 and 2005, there were 241,497 deliveries within the Southern California Kaiser healthcare system. Among these, we identified 60 cases of PC by searching for an International Classification of Diseases, Ninth Edition diagnosis of heart failure (HF) and detailed chart review. PC was confirmed if all of the following criteria were satisfied: (1) left ventricular ejection fraction <0.50, (2) met the Framingham criteria for HF, (3) new symptoms of HF or initial echocardiographic diagnosis of left ventricular dysfunction occurred in the month before or in the 5 months after delivery, and (4) no alternative cause of HF could be identified. The overall incidence of PC was 1 in 4,025 deliveries. The incidence in whites, African-Americans, Hispanics, and Asians was 1 of 4,075, 1 of 1,421, 1 of 9,861, and 1 of 2,675 deliveries, respectively. The incidence of PC was greatest in African-Americans, which was 2.9-fold higher compared with whites (p = 0.03) and 7-fold that of Hispanics (p <0.001). With a mean follow-up of 4.7 years, the freedom from all-cause death was 96.7% by the Kaplan-Meier method. In conclusion, this large population-based study highlights important racial differences in the incidence of PC. We observed the lowest incidence of PC in Hispanics and the highest in African-Americans. Our findings also suggest that the current mortality associated with PC may be less than reported in older series, perhaps because of the high utilization of modern HF therapy.

WITHDRAWN: Cardiac Troponin T: An Early Molecule Marker of Normalization of Left Ventricular Ejection Fraction in Patients with Peripartum Cardiomyopathy

The article entitled, "Cardiac Troponin T: An Early Molecule Marker of Normalization of Left Ventricular Ejection Fraction in Patients with Peripartum Cardiomyopathy", by Li et al, which originally was published in this space, has been removed because an article by the same authors and reporting very similar work already has been published in HEART [Published Online First: 25 October 2006], entitled, "Troponin T measurement can predict persistent left ventricular dysfunction in peripartum cardiomyopathy", by Hu et al. The printed version of the article in HEART can be found at Heart 2007;93:488-490.

Peripartum cardiomyopathy: a comprehensive review

Peripartum cardiomyopathy (PPCM) is a rare disorder in which left ventricular dysfunction and symptoms of heart failure occur in the peripartum period in previously healthy women. Incidence of PPCM ranges from 1 in 1300 to 1 in 15,000 pregnancies. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The diagnostic criteria are onset of heart failure in the last month of pregnancy or in first 5 months postpartum, absence of determinable cause for cardiac failure, and absence of a demonstrable heart disease before the last month of pregnancy. Risk factors for PPCM include advanced maternal age, multiparity, African race, twinning, gestational hypertension, and long-term tocolysis. The clinical presentation of patients with PPCM is similar to that of patients with dilated cardiomyopathy. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Treatment is similar to medical therapy for other forms of dilated cardiomyopathy. About half the patients of PPCM recover without complications. The prognosis is poor in patients with persistent cardiomyopathy. Persistence of disease after 6 months indicates irreversible cardiomyopathy and portends worse survival.

Management of a case of peripartum cardiomyopathy

Background A 49-year-old woman presented at hospital, 8 days after giving birth to twins, with signs and symptoms of congestive heart failure. She had no history of heart disease, exposure to cardiotoxic agents or family history of heart muscle disease. Investigations Physical examination and laboratory blood tests, electrocardiography, transthoracic echocardiography. Diagnosis Peripartum cardiomyopathy. Management Standard heart failure therapy including beta-blockers, angiotensin-converting-enzyme inhibitors, diuretics and systemic anticoagulation.

Troponin T measurement can predict persistent left ventricular dysfunction in peripartum cardiomyopathy

OBJECTIVE

To determine whether measurement of cardiac troponin T (cTnT) concentration in newly diagnosed peripartum cardiomyopathy (PPCM) can be used to predict persistent left ventricular dysfunction after a 6-month follow-up.

PATIENTS AND METHODS

This was a prospective, multiple-centre clinical trial that studied 106 patients with newly diagnosed PPCM surviving over 6 months. cTnT concentration was measured within 2 weeks of the onset of PPCM.

RESULTS

Serum cTnT concentration was negatively correlated with left ventricular ejection fraction (LVEF) at follow-up (LVEF, r = -0.518, p = 0.0001). Analysis by receiver operator characteristic curve yielded an area under the curve of 0.764 (95% CI 0.669 to 0.860, p = 0.0001, vs null hypothesis value 0.5) for cTnT, and a cTnT concentration cut off of >0.04 ng/ml, predicting persistent left ventricular dysfunction with a sensitivity of 54.9% and a specificity of 90.9%. Among 106 recruited patients, there were 33 patients with cTnT concentrations >0.04 ng/ml and 73 patients with cTnT concentrations < or =0.04 ng/ml. After a 6-month follow-up, there was significantly smaller LVEF (35.42% (13.04% vs 50.16% (10.48%, p = 0.0001) and more persistent left ventricular dysfunction (84.8% vs 31.5%, OR = 12.17 (95% CI 4.17 to 35.57), p = 0.001) in patients with cTnT >0.04 ng/ml than in patients with cTnT < or =0.04 ng/ml.

CONCLUSION

Serum cTnT concentration measured within 2 weeks of the onset of PPCM was correlated negatively with LVEF at follow-up. This marker offers a simple, quick, inexpensive, non-invasive method for predicting a persistent LVEF of < or =50%. A cTnT concentration of >0.04 ng/ml predicted persistent left ventricular dysfunction with a sensitivity of 54.9% and a specificity of 90.9%.

Improved outcomes in peripartum cardiomyopathy with contemporary

BACKGROUND

Prior studies have shown both high morbidity and mortality for patients with peripartum cardiomyopathy (PPCM). These studies were small and predated current advances in heart failure treatment. We sought to determine the outcomes of women with PPCM in the contemporary era and to determine predictors of poor outcome.

METHODS

Patients with PPCM from 1990 to 2003 were identified retrospectively through screening of heart failure clinics and echocardiography records. Their records were reviewed, and current clinical status was determined.

RESULTS

Fifty-five patients were identified with an average follow-up of 43 months. Their mean initial ejection fraction (EF) was 20%. Compared with their initial EF, 62% of patients improved, 25% were unchanged, and 4% declined. No patients died, and 10% eventually required transplant. At 2 months after diagnosis, 75% of those who eventually recovered had an EF >45%. Factors associated with lack of recovery at initial assessment were a left ventricular (LV) end-diastolic dimension >5.6 cm, the presence of LV thrombus, and African-American race. Recovery of LV function was not predicted by the initial EF. Among patients who recovered, the withdrawal of heart failure medications was not associated with decompensation over a follow-up of 29 months.

CONCLUSIONS

The morbidity related to PPCM is less than previously reported. Initial LV end-diastolic dimension and EF at 2 months predict long-term outcomes. The discontinuation of heart failure medications after recovery did not lead to decompensation.

Peripartum cardiomyopathy

OBJECTIVE

To determine the clinical and echocardiographic profiles of women with peripartum cardiomyopathy and ascertain the natural course of the disease.

METHODS

Fifty-six women with peripartum cardiomyopathy were followed up for a mean period of 6.1 years and their clinical and echocardiographic profiles were studied as well as their outcomes.

RESULTS

The mean+/-SD age at presentation was 31+/-5 years and mean parity was 2.6+/-1. Of the 56 patients, 18 (32.1%) had NYHA Class II, 24 (42.9%) had NYHA Class III, and 14 (25%) had NYHA Class IV symptoms, and 21 (37.5%) and 35 (62.5%), respectively, presented with features of heart failure during pregnancy and the postpartum. During follow-up, the left ventricular ejection fraction improved from 31%+/-7.2% to 43%+/-8% (P</=0.05). Nine patients (16.1%) became pregnant, with a mortality of 55.5% during pregnancy and 23.2% during follow-up.

CONCLUSION

Women with peripartum cardiomyopathy present with severe left ventricular dysfunction late in the pregnancy or early in the puerperium. A considerable number of women still die from this condition despite the use of angiotensin-converting enzyme inhibitors and beta-blockers. A subsequent pregnancy carries a very high risk of mortality.

Delayed hyperenhancement magnetic resonance imaging is useful in predicting functional recovery of nonischemic left ventricular systolic dysfunction

BACKGROUND

About 25% of the patients with nonischemic left ventricular (LV) systolic dysfunction improve spontaneously. However, the predictors for functional improvement are not known. We hypothesized that myocardial fibrosis, assessed by cardiac magnetic resonance (CMR) imaging, may predict the reversibility of nonischemic LV systolic dysfunction.

METHODS AND RESULTS

CMR was performed in 46 patients. Baseline and follow-up echocardiography was performed to assess the recovery of LV function. There were 24 patients with absence of delayed hyperenhancement (group 1) and 22 patients with delayed hyperenhancement (group 2). There were significant difference for the follow-up LV end-diastolic dimension (56.2 +/- 7.3 versus 62.6 +/- 11.9), LV end-systolic dimension (43.2 +/- 9.2 versus 52.8 +/- 12.6), and LV ejection fraction (LVEF) (46.8 +/- 12.4% versus 31.6 +/- 11.3%). Follow-up echocardiography of 19/24 (79.2%) patients in group 1 showed functional recovery, whereas only 2/22 (9.1%) patient in group 2 showed functional recovery. The absence of delayed hyperenhancement was associated with sensitivity, specificity, positive predictive value, and negative predictive value of 90.5%, 79.2%, 80.0%, and 90.9%, respectively.

CONCLUSION

Absence of delayed hyperenhancement demonstrated excellent sensitivity and negative predictive value in predicting functional recovery of nonischemic LV systolic dysfunction.

Frequency of peripartum cardiomyopathy

Reports from case series have estimated the incidence of peripartum cardiomyopathy (PC) at 1 case/1,485 live births to 1 case/15,000 live births and probable mortality rates of 7% to 60%. The objective of this study was to produce the first population-based study of the incidence, mortality, and risk factors for PC. The National Hospital Discharge Survey was used. Discharge information was available for 3.6 million patient discharges from 1990 to 2002. There were an estimated 16,296 cases of PC from 1990 to 2002. During this period, there were 51,966,560 live births in the United States. Thus, the incidence of PC was 1 case/3,189 live births. There was a trend toward an increase in PC incidence during the study period, with an estimate for the years 2000 to 2002 of 1 case/2,289 live births. The in-hospital mortality rate was 1.36% (95% confidence interval 0% to 10.2%). The total mortality rate was 2.05% (95% confidence interval 0.29% to 10.8%). Patients with PC were older (mean age 29.7 vs 26.9 years), were more likely to be black (32.2% vs 15.7%), and had a higher incidence of pregnancy associated hypertensive disorders (22.5% vs 5.87%) compared with national data. In conclusion, the incidence of PC is relatively uncommon, occurring at an average frequency of 1 case/3,189 live births from 1990 to 2002. The estimated mortality of 1.36% to 2.05% (95% confidence interval 0.29% to 10.8%) is less than previously reported from most case series.

Isolated noncompaction of left ventricle presenting as peripartum cardiomyopathy

Long term follow-up of the first reported case of isolated noncompaction of left ventricle presenting as peripartum cardiomyopathy is presented.

Epidemiology and Etiology of Cardiomyopathy in Africa

Background— Cardiomyopathy, an often irreversible form of heart muscle disease that is associated with a dismal outcome, is endemic in Africa. The primary objective of this review was to summarize the current state of knowledge on the epidemiology and etiology of cardiomyopathy in people living in Africa and to identify new avenues for research.

Methods and Results— We searched MEDLINE (January 1, 1966, through February 12, 2005) and reference lists of articles for relevant references. Unlike other parts of the world in which cardiomyopathy is rare, dilated cardiomyopathy is a major cause of heart failure throughout Africa. Similarly, peripartum cardiomyopathy is ubiquitous on the continent, with an incidence ranging from 1 in 100 to 1 in 1000 deliveries. There is an apparent marked regional variation in the pathogenesis of dilated cardiomyopathy and peripartum cardiomyopathy, underlining the heterogeneity of causative factors in these conditions. By contrast, endomyocardial fibrosis is restricted to the tropical regions of East, Central, and West Africa. Although the pathogenesis of endomyocardial fibrosis is not fully understood, it seems that the conditioning factors are geography and diet, the triggering factor may be an as yet unidentified infective agent, and the perpetuating factor is eosinophilia. Although epidemiological studies are lacking, hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy seem to have characteristics similar to those of other populations elsewhere in the world.

Conclusions— There is a need for large-scale epidemiological studies of the incidence, prevalence, determinants, and outcome of cardiomyopathy in Africa to inform strategies for the treatment and prevention of heart muscle disease on the continent.

Severe cardiac disease in pregnancy, part II: impact of congenital and acquired cardiac diseases during pregnancy

PURPOSE OF REVIEW

Part II of this review gives an overview of the different maternal cardiac problems during pregnancy and their management, and developments over recent years.

RECENT FINDINGS

Many studies published over the last 5 years provided new insights on different cardiac diseases in pregnancy. Publications discussed in this part of the review on cardiac disease in pregnancy, for example, provide epidemiological data on heart disease during pregnancy in general, and cardiomyopathy and ischemic heart disease in particular. In addition, we discussed the implications of a history of peripartum cardiomyopathy for a subsequent pregnancy, interventional strategies during pregnancy in women with ischemic heart disease, and the role of echocardiography in the evaluation of cardiac disease in pregnancy.

SUMMARY

The prevalence of the different causes of heart disease has shifted towards congenital heart disease by the end of the millennium. In developing countries, relatively rare diseases like rheumatic fever are still common, so these diseases are increasingly 'exported' to developed countries. The group of women with congenital heart disease represents most women with heart disease during pregnancy, followed by rheumatic heart disease. With the exception of patients with Eisenmenger's syndrome, pulmonary vascular obstructive disease, and Marfan's syndrome with aortopathy, maternal death during pregnancy is rare in women with heart disease. Although the risk for mortality is low in pregnant women with preexistent cardiac disease, these women are at increased risk for serious morbidity such as heart failure, arrhythmias, and stroke.

Peripartum cardiomyopathy

OBJECTIVE

To provide a review of the cardiac and obstetrical literature regarding the development of peripartum cardiomyopathy and, in particular, to examine risk factors, incidence, diagnosis, prognosis, and evidence-based treatment modalities.

DESIGN

An extensive review of the current literature.

RESULTS

Peripartum cardiomyopathy is a cardiomyopathy of unknown cause that occurs in pregnant females, most commonly in the early postpartum period. It shares many clinical characteristics with idiopathic dilated cardiomyopathy but occurs at a younger age and is associated with a better prognosis. Diagnosis is based upon the clinical presentation of congestive heart failure and objective evidence of left ventricular systolic dysfunction. Conventional pharmacologic therapy for congestive heart failure, such as diuretics, digoxin, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and beta-adrenergic blockers, are routinely used and are quite effective. For those patients who remain refractory to conventional pharmacologic therapy, cardiac transplantation and mechanical circulatory support are viable options.

CONCLUSION

Mortality rates in peripartum cardiomyopathy have decreased, and this is most likely related to advances over the past 5 yrs in medical therapy for heart failure. Aggressive use of implantable defibrillators has significantly reduced the risk of sudden death in these patients. For >50% of peripartum cardiomyopathy patients, left ventricular function normalizes with pharmacologic therapy. However, subsequent pregnancies almost always are associated with recurrence of left ventricular systolic dysfunction.

Peripartum cardiomyopathy: inflammatory markers as predictors of outcome in 100 prospectively studied patients

AIMS

Peripartum cardiomyopathy (PPCM) is a disorder of unknown aetiology with a course and outcome that is largely unpredictable. We evaluated the prognostic role of multiple inflammatory markers in the plasma of a large cohort of African patients with PPCM.

METHODS AND RESULTS

The study of 100 patients with newly diagnosed PPCM was single-centred, prospective, and longitudinal. Clinical assessment, echocardiography, and blood analysis were done at baseline and after 6 months of standard therapy. Inflammatory markers were measured at baseline only. Fifteen patients died. Left ventricular ejection fraction (LVEF) improved from 26.2+/-8.2 to 42.9+/-13.6% at 6 months (P<0.0001). However, normalization of LVEF (>50%) was only observed in 23%. Baseline levels of C-reactive protein correlated positively with baseline LV end-diastolic (rs=0.33, P=0.0026) and end-systolic (rs=0.35, P=0.0012) diameters and inversely with LVEF (rs=-0.27, P=0.015). Patients who died presented with significantly lower mean EF and higher Fas/Apo-1 plasma values (P<0.05). Fas/Apo-1 and New York Heart Association functional class (NYHA FC) predicted mortality at baseline.

CONCLUSION

Plasma markers of inflammation were significantly elevated and correlated with increased LV dimensions and lower LVEF at presentation. Baseline Fas/Apo-1 and higher NYHA FC were the only predictors of mortality. Normalization of LVEF was only observed in 23% of this African cohort.

Acute non-traumatic maternal illnesses in pregnancy: imaging approaches

The imaging methods used to obtain diagnostic information for pregnant patients presenting with acute non-traumatic maternal illnesses have been reviewed. Conditions affecting the gastrointestinal tract, urinary tract, uterus, adnexae, central nervous system and chest have been investigated via a variety of imaging methods, which include ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), intravenous pyelography (IVP), angiography and fluoroscopy. The method of choice, application, and safety to the mother and fetus are considered for investigation of each condition.

Left ventricular apical infection and rupture complicating left ventricular assist device explantation in 2 women with postpartum cardiomyopathy

Postpartum cardiomyopathy is rare form of cardiac failure, with the potential for cardiac function to recover to normal. When medical therapy fails to control symptoms or haemodynamic stability, circulatory support with a ventricular assist device may be considered as a bridge to cardiac transplantation. We describe 2 patients with severe postpartum cardiomyopathy, in whom cardiac function recovered sufficiently during mechanical circulatory assistance to enable device explantation. Bacteremia during device support was treated with chronic suppressive antibiotics, yet after cannula explantation and ventricular repair, residual infection led to destruction of the primary repair, with formation of a left ventricular pseudoaneurysm. This is a complication of device support not previously reported. Surgery was necessary to repair the infected ventricular cannula site. Both patients recovered; however one patient developed recurrent cardiomyopathy 4 months later.

Pregnancy-Related Maternal Deaths

Pregnancy is a normal biologic process, but because of a variety of physiologic factors, it increases a woman's risk for death. Maternal deaths in pregnancy may be due to conditions unique to pregnancy, conditions associated with pregnancy, or conditions unrelated to but exacerbated by pregnancy. Death may occur during any trimester, during labor/birth, or postpartum. In this report, we present 45 cases of pregnancy-related maternal deaths that were investigated and autopsied at the Dallas County Medical Examiners office between 1977 and 1999, and we review the topic of pregnancy-related maternal death.

Outcome of subsequent pregnancy in patients with documented peripartum cardiomyopathy

Subsequent pregnancy in 6 patients with previous peripartum cardiomyopathy resulted in reduction of ejection fraction by >10% in 5 patients at 1 month postpartum. Two patients with impaired ejection fraction at onset of subsequent pregnancy died 3 months postpartum due to heart failure despite optimal medical therapy. Deterioration of left ventricular function occurred uniformly postpartum and was accompanied by elevation of tumor necrosis factor-alpha plasma levels from 2.4 +/- 1.1 pg/ml at onset of subsequent pregnancy to 6.2 +/- 2.4 pg/ml at 1 month postpartum.

Successful Use of Levosimendan in a Patient with Peripartum Cardiomyopathy

This case represents the first reported use of levosimendan, a calcium-sensitizing drug with additional vasodilation properties, for treatment of a woman with peripartum cardiomyopathy. Levosimendan induced a steady decline of increased pulmonary capillary wedge pressure, followed by a definitive increase in cardiac stroke volume. The patient recovered from this serious episode of heart failure, and she ultimately regained left ventricular function.

IMPLICATIONS

Acute heart failure is a life-threatening event that only rarely occurs during childbirth. We report a case of a woman who experienced cardiovascular collapse during vaginal delivery. We determined that she met current diagnostic criteria for peripartum cardiomyopathy, and we successfully treated her with levosimendan, a calcium-sensitizing drug with additional vasodilation properties.

Pregnancy as a stressful life event

Pregnancy and childbirth typically are associated with positive emotions and with motherhood, but the reality is that this is not the case for all women or for all pregnancies. This review addresses a different aspect of these reproductive events, focusing on stressful circumstances surrounding pregnancy, as well as times when the pregnancy itself becomes a stressful life event. Pregnancy-related topics that tend to receive less attention will be emphasized. These include issues related to infertility; unplanned pregnancy; stress associated with testing and diagnosis of common medical complications; peripartum cardiomyopathy; fear of childbirth; and pregnancy loss as a risk factor for psychopathology. Epidemiologic information will be presented, as will relevant psychosocial factors related to each phenomenon. Healthcare providers should be sensitive to the distress and anxiety experienced by many women and their families as a consequence of these adverse events and the stressful challenge of any consequential decision-making, as well as stressors in their broader life context that can further exacerbate their distress, and make mental health referrals as appropriate.

Pregnancy-related mortality due to cardiomyopathy: United States, 1991-1997

OBJECTIVE

To describe characteristics and risk factors for pregnancy-related deaths due to cardiomyopathy during 1991-1997 and to assess reasons for the increasing trend in reporting of pregnancy-related deaths due to cardiomyopathy from 1979 through 1997.

METHODS

We used data from the Centers for Disease Control (CDC) and Prevention's Pregnancy Mortality Surveillance System to examine pregnancy-related deaths due to cardiomyopathy from 1991 through 1997. The pregnancy-related mortality ratio for cardiomyopathy was defined as the number of pregnancy-related deaths from cardiomyopathy per 100,000 live births. Cardiomyopathy was classified as peripartum cardiomyopathy or cardiomyopathy due to other causes.

RESULTS

Of the 245 cardiomyopathy deaths that occurred during 1991-1997, 171 (70%) were due to peripartum cardiomyopathy. The cause-specific pregnancy-related mortality ratio was 0.88 per 100,000 live births. Mortality increased as maternal age increased. Black women were 6.4 times as likely to die from cardiomyopathy as white women. Among peripartum cardiomyopathy cases in which the interval from the end of pregnancy was known, 2% died undelivered, 48% died within 42 days of delivery, and 50% died between 43 days and 1 year postpartum.

CONCLUSION

Cardiomyopathy accounts for an increasing proportion of reported pregnancy-related deaths, and the more than six-fold excess risk of death from cardiomyopathy among black women is larger than that for any other cause of death. The increased reporting of these deaths might be largely due to improved case ascertainment. Further studies are required to estimate the prevalence of cardiomyopathy and identify modifiable risk factors associated with these deaths and the reasons for this racial disparity.

Peripartum cardiomyopathy: a condition intensivists should be aware of

We use an illustrative case of severe peripartum cardiomyopathy with congestive heart failure to introduce this topic and proceed to cover its pathophysiology, incidence, management and outcome.

Peripartum cardiomyopathy and thromboembolism; anesthetic management and clinical course of an obese, diabetic patient

PURPOSE

To describe the anesthetic management and clinical course of a patient with peripartum cardiomyopathy. We highlight the frequent occurrence of thromboembolic morbidity in this group of parturients, emphasizing the need for early consideration of prophylactic anticoagulation.

CLINICAL FEATURES

A 38-yr-old, diabetic, obese parturient was admitted with pulmonary edema and severe orthopnea at 31 weeks gestation. The respiratory rate was 44 breaths x min(-1), blood pressure 110/70 mmHg, pulse 120 beats x min(-1) and rales were heard in both lung fields. The diagnosis of peripartum cardiomyopathy was made based on sinus tachycardia with no evidence of ischemia on the electrocardiogram, and global left ventricular hypokinesis with an ejection fraction of 40-45% noted on transthoracic echocardiography. Cesarean delivery was planned to improve maternal respiratory status and hemodynamics. General anesthesia with invasive monitoring was planned, and surgery and anesthesia proceeded uneventfully. Less than 24 hr postoperatively, she sustained a thrombotic cerebral infarct leaving her hemiparetic and dysarthric. Subsequent investigations revealed a thrombophilic state due to elevated anticardiolipin antibody.

CONCLUSION

General anesthesia is an acceptable option in parturients with heart failure secondary to cardiomyopathy. Thromboembolic complications are common, and early consideration should be given to prophylactic anticoagulation.

Peripartum cardiomyopathy: a forgotten diagnosis?

Peripartum cardiomyopathy (PPCM) is a rare form of left ventricular failure with potentially fatal consequences, occurring during the last month of pregnancy or within the first 5 months after delivery. Diagnosis is by excluding all other causes of left ventricular failure and demonstrating characteristic echocardiographic findings. Management is similar to that of left ventricular failure of other causes.

Autoimmune mechanisms as the basis for human peripartum cardiomyopathy

The etiology and mechanisms of pathogenesis of human peripartum cardiomyopathy (PPCM) remain unknown. The incidence and prevalence of this disease is rare in some parts of the world and more common in others. The purpose of this review is to summarize our current knowledge of the factors that have been entertained which may contribute to the pathogenesis of PPCM with special emphasis on more recent data from our laboratory that provide support to the view that this disease is an autoimmune disease with multiple contributing factors and effector mechanisms. This is supported by the fact that sera from PPCM patients contain high titers of auto-antibodies against normal human cardiac tissue proteins of 37, 33, and 25 kD that was not present in the sera of patients with idiopathic cardiomyopathy (IDCM), indicating for the first time that PPCM is distinct from IDCM. In addition to the autoantibodies, the PBMC's from PPCM patients demonstrate a heightened level of fetal microchimerism, an abnormal cytokine profile, decreased levels of CD4+ CD25lo regulatory T cells, and a significant reduction in the plasma levels of progesterone, estradiol and relaxin in PPCM patients as compared with other normal pregnant non-PPCM patients. A potential role for reduced plasma levels of selenium in the pathogenesis of select PPCM patients was also noted. These findings for the first time suggest that such abnormalities may in concert lead to the initiation and perpetuation of an autoimmune process, which leads to cardiac failure and disease. Identification of the precise nature of the cardiac tissue autoantigens (currently in progress) will pave the way for the delineation of mechanism of this autoimmune disease. A working model for the pathogenesis of this disease is also described herein.

Peripartum cardiomyopathy and biventricular thrombi

Peripartum cardiomyopathy is a rare cardiac disorder characterized by the development of heart failure in the last month of pregnancy or up to 5 months postpartum in women without other determinable causes of cardiac failure. Intracardiac thrombi have been found at autopsy in some patients with this condition and have been demonstrated in the left or right ventricles on 2-dimensional echocardiography. A 23-year-old woman presented with peripartum cardiomyopathy and biventricular thrombi on echocardiography. The thrombi were spherical, pedunculate, shaggy and irregular in configuration, and freely mobile, suggesting that they were fresh. She was treated with conventional heart failure therapy and anticoagulants. Four days later, the apical thrombi within both ventricles had disappeared and there was no evidence of embolism on physical examination. The hypercoagulable state of the peripartum period and the severe biventricular dysfunction most likely led to the formation of biventricular thrombi.

Is peripartum cardiomyopathy an organ-specific autoimmune disease?

Peripartum cardiomyopathy (PPCM) is a rare and serious heart disease that exclusively afflicts women during childbearing years. Symptoms include rapid onset of cardiovascular insufficiency occurring during pregnancy, initiated anytime between the third trimester until 5 months post-partum in the absence of any other signs or history of heart disease. The rare incidence of PPCM and the absence of any relevant animal models have limited research and understanding of the pathogenic mechanisms involved. Several compelling sets of data support the view that PPCM is a form of autoimmune IDCM. However, PPCM differs from autoimmune IDCM in that (a) it is associated with unique sets of autoantibodies and autoantigens, (b) it has a relatively rapid onset, and (c) it exclusively affects pregnant women. Furthermore, the etiology of PPCM is dependent on the interaction of pregnancy associated factors, e.g. increased hemodynamic stress, vasoactive hormones and fetal microchimerism, that co-operate in the context of essential immune and genetic environments for disease progression. Our model of PPCM attempts to represent how multiple factors, e.g. pregnancy, genetics, immune dysregulation, and fetal microchimerism are held in a complex dynamic balance that can co-operate towards the maintenance of cardiovascular health or disease in the mother (Fig. 1). A more thorough study of the precise nature of the cardiac tissue autoantigens may lead to the identification of the mechanisms of breakdown of self-tolerance and perhaps also the putative etiologic agent(s). Further studies of the precise nature of the cardiac tissue autoantigens and the specific factors governing the balance between tolerance and autoimmunity in the periphery, e.g. expression of PD-L1 on cardiac tissues and the role of regulatory T cells, may help to elucidate the autoimmune mechanisms of PPCM.

Echocardiographic features of peripartum cardiac failure: the Zaria syndrome

Zaria has the highest incidence of peripartum cardiac failure, a syndrome of unsettled aetiology. Over the years it has been noted that there has been a decrease in the period of treatment by traditional methods from an average of 90 days to 30 days and with a complete avoidance of hot bed treatment. Twenty-one subjects with the syndrome were studied: they exhibited the same clinical findings as evinced in previous reports from our centre. Echocardiography findings of dilated heart with depressed left ventricular function were noted. There was a statistically significant relationship between the duration of practice and ejection fraction (EF), r=0.36 and P<0.05, duration of practice and left ventricular internal diameter in diastole (LVIDd), r=0.28, P<0.05. Were these subjects suffering from a quiescent heart muscle disease from a previous viral myocarditis and did they require an expanded volume as a trigger? Or are they intolerant of salt requiring only a small increase from the traditional method of treatment to precipitate cardiac failure? Further investigation in the field of molecular biology is required.

[Peripartum idiopathic myocardiopathy: prospective echocardiographic study]

Still frequent in Africa, the idiopathic peripartum cardiomyopathy (PPC) is the subject of only few prospective studies. The aim of this prospective work was to assess the echocardiographic abnormalities of the PPC and to determine on 26 patients the evolution and the prognostic factors of this disease. Six women had mild to moderate pericardial effusion. The abnormalities of the wall motion, constantly found, were diffuse in 20 cases (77.1%) and localized or prevalent on the interventricular septum or the left ventricular posterior wall in the other cases. The cardiac chambers were dilated in 24 cases (92.3%). Left ventricular hypertrophy was noted among 16 patients (61.5%); it was eccentric in 15 cases. The left ventricular systolic dysfunction was constant. The other abnormalities were: the abnormal left ventricular relaxation (one case), low mitral and aortic flow (12 cases), the mitral (21 cases) and tricuspid regurgitation (five cases). One noted a septal hypertrophy and an isolated dilatation of the right ventricle. The mean follow-up was 7.3 +/- 1 month (1-18 months). Two patients died at the 4th and 8th month. Among the 24 survivors, 11 had normalized were: the gestity (p = 0.01), the parity (p = 0.01), the cardiothoracic ratio (p = 0.04), the left ventricular volumes (p = 0.02), and the parameters of left ventricular function. The echocardiography of patients with PPC usually shows a pattern of dilated and hypokinetic cardiomyopathy, but many variations are possible. Most of the patients keep echocardiographic abnormalities after mean term follow-up.