Clinical significance of endomyocardial biopsy in conjunction with cardiac magnetic resonance imaging to predict left ventricular reverse remodeling in idiopathic dilated cardiomyopathy

Relationship Between Results of Pathological Evaluation of Endomyocardial Biopsy and Echocardiographic Indices in Patients With Non-Ischemic Cardiomyopathy

Background: Endomyocardial biopsy (EMB) is a useful modality in diagnosing the origin of cardiomyopathy and the condition of the impaired myocardium. However, the usefulness of obtaining an EMB from the right and left ventricles (RV and LV, respectively), and its associations with echocardiographic parameters, have not been explored. Methods and Results: Ninety-five consecutive patients with non-ischemic cardiomyopathy excluding myocarditis who underwent EMB between July 2017 and May 2019 were studied. Seventy-nine RV and 93 LV biopsy specimens were pathologically analyzed. The relationships among echocardiographic data before EMB and pathologically measured cardiomyocyte diameter (CMD) and interstitial fibrosis (IF) were evaluated. CMD in both LV and RV specimens correlated with echocardiographic LV morphology, but only CMD in the LV was significantly correlated with cardiac function evaluation, including LV ejection fraction, E' and E/E'. In contrast, there were no significant correlations between IF in either the LV or RV and any echocardiographic parameters measured. Furthermore, CMD of both ventricles was significantly correlated with B-type natriuretic peptide (BNP) concentration at EMB, whereas IF of the LV was barely related and IF of the RV was not significantly correlated with BNP concentrations. Conclusions: Pathologically evaluated CMD of EMB specimens of the LV may be more related to functional parameters for heart failure status and LV geometry on echocardiographic examination, than IF.

T1 Map-Based Radiomics for Prediction of Left Ventricular Reverse Remodeling in Patients With Nonischemic Dilated Cardiomyopathy

OBJECTIVE

This study aimed to develop and validate models using radiomics features on a native T1 map from cardiac magnetic resonance (CMR) to predict left ventricular reverse remodeling (LVRR) in patients with nonischemic dilated cardiomyopathy (NIDCM).

MATERIALS AND METHODS

Data from 274 patients with NIDCM who underwent CMR imaging with T1 mapping at Severance Hospital between April 2012 and December 2018 were retrospectively reviewed. Radiomic features were extracted from the native T1 maps. LVRR was determined using echocardiography performed ≥ 180 days after the CMR. The radiomics score was generated using the least absolute shrinkage and selection operator logistic regression models. Clinical, clinical + late gadolinium enhancement (LGE), clinical + radiomics, and clinical + LGE + radiomics models were built using a logistic regression method to predict LVRR. For internal validation of the result, bootstrap validation with 1000 resampling iterations was performed, and the optimism-corrected area under the receiver operating characteristic curve (AUC) with 95% confidence interval (CI) was computed. Model performance was compared using AUC with the DeLong test and bootstrap.

RESULTS

Among 274 patients, 123 (44.9%) were classified as LVRR-positive and 151 (55.1%) as LVRR-negative. The optimism-corrected AUC of the radiomics model in internal validation with bootstrapping was 0.753 (95% CI, 0.698-0.813). The clinical + radiomics model revealed a higher optimism-corrected AUC than that of the clinical + LGE model (0.794 vs. 0.716; difference, 0.078 [99% CI, 0.003-0.151]). The clinical + LGE + radiomics model significantly improved the prediction of LVRR compared with the clinical + LGE model (optimism-corrected AUC of 0.811 vs. 0.716; difference, 0.095 [99% CI, 0.022-0.139]).

CONCLUSION

The radiomic characteristics extracted from a non-enhanced T1 map may improve the prediction of LVRR and offer added value over traditional LGE in patients with NIDCM. Additional external validation research is required.

Association of Late-Gadolinium Enhancement in Cardiac Magnetic Resonance with Mortality, Ventricular Arrhythmias, and Heart Failure in Patients with Non-Ischemic Cardiomyopathy: A Systematic Review and Meta-Analysis

Background

Late gadolinium enhancement (LGE) on cardiac magnetic resonance is a predictor of adverse events in patients with nonischemic cardiomyopathy (NICM).

Objective

This meta-analysis evaluated the correlation between LGE and mortality, ventricular arrhythmias (VAs) and sudden cardiac death (SCD), and heart failure (HF) outcomes.

Methods

A literature search was conducted for studies reporting the association between LGE in NICM and the study endpoints. The primary endpoint was mortality. Secondary endpoints included VA and SCD, HF hospitalization, improvement in left ventricular ejection fraction (LVEF) to >35%, and heart transplantation referral. The search was not restricted to time or publication status. The minimum follow-up duration was 1 year.

Results

A total of 46 studies and 10,548 NICM patients (4610 with LGE, 5938 without LGE) were included; mean follow-up was 3 years (range 13-71 months). LGE was associated with increased mortality (odds ratio [OR] 2.9; 95% confidence interval [CI] 2.3-3.8; P < .01) and VA and SCD (OR 4.6; 95% CI 3.5-6.0; P < .01). LGE was associated with an increased risk of HF hospitalization (OR 3.4; 95% CI 2.3-5.0; P < .01), referral for transplantation (OR 5.1; 95% CI 2.5-10.4; P < .01), and decreased incidence of LVEF improvement to >35% (OR 0.2; 95% CI 0.03-0.85; P = .03).

Conclusion

LGE in NICM patients is associated with increased mortality, VA and SCD, and HF hospitalization and heart transplantation referral during long-term follow up. Given these competing risks of mortality and HF progression, prospective randomized controlled trials are required to determine if LGE is useful for guiding prophylactic implantable cardioverter-defibrillator placement in NICM patients.

Heart failure with recovered ejection fraction: Current understanding and future prospects

Heart failure with reduced ejection fraction (HFrEF) is a prevalent kind of heart failure in which a significant amount of the ejection fraction can be repaired, and left ventricular remodeling and dysfunction can be reversed or even restored completely. However, a considerable number of patients still present clinical signs and biochemical features of incomplete recovery from the pathophysiology of heart failure and are at risk for adverse outcomes such as re-deterioration of systolic function and recurrence of HFrEF. Furthermore, it is revealed from a microscopic perspective that even if partial or complete reverse remodeling occurs, the morphological changes of cardiomyocytes, extracellular matrix deposition, and abnormal transcription and expression of pathological genes still exist. Patients with "recovered ejection fraction" have milder clinical symptoms and better outcomes than those with continued reduction of ejection fraction. Based on the unique characteristics of this subgroup and the existence of many unknowns, the academic community defines it as a new category-heart failure with recovered ejection fraction (HFrecEF). Because there is a shortage of natural history data for this population as well as high-quality clinical and basic research data, it is difficult to accurately evaluate clinical risk and manage this population. This review will present the current understanding of HFrecEF from the limited literature.

Cardiac remodelling - Part 2: Clinical, imaging and laboratory findings. A review from the Study Group on Biomarkers of the Heart Failure Association of the European Society of Cardiology

In patients with heart failure, the beneficial effects of drug and device therapies counteract to some extent ongoing cardiac damage. According to the net balance between these two factors, cardiac geometry and function may improve (reverse remodelling, RR) and even completely normalize (remission), or vice versa progressively deteriorate (adverse remodelling, AR). RR or remission predict a better prognosis, while AR has been associated with worsening clinical status and outcomes. The remodelling process ultimately involves all cardiac chambers, but has been traditionally evaluated in terms of left ventricular volumes and ejection fraction. This is the second part of a review paper by the Study Group on Biomarkers of the Heart Failure Association of the European Society of Cardiology dedicated to ventricular remodelling. This document examines the proposed criteria to diagnose RR and AR, their prevalence and prognostic value, and the variables predicting remodelling in patients managed according to current guidelines. Much attention will be devoted to RR in patients with heart failure with reduced ejection fraction because most studies on cardiac remodelling focused on this setting.

Cardiac Remodeling in Hypertension: Clinical Impact on Brain, Heart, and Kidney Function

Hypertension is the most common causative factor of cardiac remodeling, which, in turn, has been associated with changes in brain and kidney function. Currently, the role of blood biomarkers as indices of cardiac remodeling remains unclear. In contrast, cardiac imaging, including echocardiography and cardiovascular magnetic resonance (CMR), has been a valuable noninvasive tool to assess cardiac remodeling. Cardiac remodeling during the course of systemic hypertension is not the sole effect of the latter. "Remodeling" of other vital organs, such as brain and kidney, also takes place. Therefore, it will be more accurate if we discuss about "hypertensive remodeling" involving the heart, the brain, and the kidneys, rather than isolated cardiac remodeling. This supports the idea of their simultaneous assessment to identify the early, silent lesions of total "hypertensive remodeling". In this context, magnetic resonance imaging is the ideal modality to provide useful information about these organs in a noninvasive fashion and without radiation. For this purpose, we propose a combined protocol to employ MRI in the simultaneous assessment of the heart, brain and kidneys. This protocol should include all necessary indices for the evaluation of "hypertensive remodeling" in these 3 organs, and could be performed within a reasonable time, not exceeding one hour, so that it remains patient-friendly. Furthermore, a combined protocol may offer "all in one examination" and save time. Finally, the amount of contrast agent used will be limited granted that post-contrast evaluations of the three organs will be performed after 1 injection.

Impact of Autophagy on Prognosis of Patients With Dilated Cardiomyopathy

BACKGROUND

Autophagy is a cellular process that degrades a cell's own cytoplasmic components for energy provision and to maintain a proper intracellular environment. Left ventricular reverse remodeling (LVRR) promises a better prognosis for patients with dilated cardiomyopathy (DCM).

OBJECTIVES

The authors tested the hypothesis that autophagy is involved in LVRR and has prognostic value in the human failing heart.

METHODS

Using left ventricular endomyocardial biopsy specimens from 42 patients with DCM (21 LVRR-positive and 21 LVRR-negative) and 7 patients with normal cardiac function (control), the authors performed immunohistochemistry and immunofluorescent labeling of LC3 and cathepsin D and electron microscopic observation in addition to general morphometry under light microscopy.

RESULTS

The clinical characteristics of LVRR-positive patients were similar to those of the LVRR-negative patients, except for pulmonary artery pressure and left atrial dimension. Morphometry under light microscopy did not differ among specimens from DCM patients, regardless of their LVRR status. Electron microscopy revealed that autophagic vacuoles (autophagosomes and autolysosomes) and lysosomes were abundant within cardiomyocytes from DCM patients. Moreover, cardiomyocytes from LVRR-positive patients contained significantly more autophagic vacuoles with higher autolysosome ratios and cathepsin D expression levels than cardiomyocytes from LVRR-negative patients. Logistic regression analysis adjusted for age showed that increases in autophagic vacuole number and cathepsin D expression were predictive of LVRR. DCM patients who achieved LVRR experienced fewer cardiovascular events during the follow-up period.

CONCLUSIONS

The authors show that autophagy is a useful marker predictive of LVRR in DCM patients. This provides novel pathologic insight into a strategy for treating the failing DCM heart.

Clinical Effect of Pulmonary Artery Diameter/Ascending Aorta Diameter Ratio on Left Ventricular Reverse Remodeling in Patients With Dilated Cardiomyopathy

BACKGROUND

Many patients with dilated cardiomyopathy (DCM) progress to heart failure (HF), although some demonstrate left ventricular (LV) reverse remodeling (LVRR), which is associated with better outcomes. The pulmonary artery diameter (PAD) to ascending aortic diameter (AoD) ratio has been used as a prognostic predictor in patients with HF, although this tool's usefulness in predicting LVRR remains unknown.Methods and Results:Data from a prospective observational study of 211 patients diagnosed in 2000-2020 with DCM were retrospectively analyzed. Sixty-nine patients with New York Heart Association class I or II HF were included. LVRR was observed in 23 patients (33.3%). The mean LV ejection fraction (29%) and LV end-diastolic dimension (64.5 mm) were similar in patients with and without LVRR. The PAD/AoD ratio was significantly lower in patients with LVRR than those without (81.4% vs. 92.4%, respectively; P=0.003). The optimal PAD/AoD cut-off value for detecting LVRR was 0.9 according to the receiver operating characteristic curve analysis. Multivariate analysis identified a PAD/AoD ratio ≥0.9 as an independent predictor of presence/absence of LVRR. Cardiac events were significantly more common in patients with a PAD/AoD ratio ≥0.9 than those with a ratio <0.9, after a median follow up of 2.5 years (log-rank, P=0.007).

CONCLUSIONS

The PAD/AoD ratio can predict LVRR in patients with DCM.

Early Prediction of Left Ventricular Reverse Remodeling in First-Diagnosed Idiopathic Dilated Cardiomyopathy: A Comparison of Linear Model, Random Forest, and Extreme Gradient Boosting

Introduction: Left ventricular reverse remodeling (LVRR) is associated with decreased cardiovascular mortality and improved cardiac survival and also crucial for therapeutic options. However, there is a lack of an early prediction model of LVRR in first-diagnosed dilated cardiomyopathy.

Methods: This single-center study included 104 patients with idiopathic DCM. We defined LVRR as an absolute increase in left ventricular ejection fraction (LVEF) from >10% to a final value >35% and a decrease in left ventricular end-diastolic diameter (LVDd) >10%. Analysis features included demographic characteristics, comorbidities, physical sign, biochemistry data, echocardiography, electrocardiogram, Holter monitoring, and medication. Logistic regression, random forests, and extreme gradient boosting (XGBoost) were, respectively, implemented in a 10-fold cross-validated model to discriminate LVRR and non-LVRR, with receiver operating characteristic (ROC) curves and calibration plot for performance evaluation.

Results: LVRR occurred in 47 (45.2%) patients after optimal medical treatment. Cystatin C, right ventricular end-diastolic dimension, high-density lipoprotein cholesterol (HDL-C), left atrial dimension, left ventricular posterior wall dimension, systolic blood pressure, severe mitral regurgitation, eGFR, and NYHA classification were included in XGBoost, which reached higher AU-ROC compared with logistic regression (AU-ROC, 0.8205 vs. 0.5909, p = 0.0119). Ablation analysis revealed that cystatin C, right ventricular end-diastolic dimension, and HDL-C made the largest contributions to the model.

Conclusion: Tree-based models like XGBoost were able to early differentiate LVRR and non-LVRR in patients with first-diagnosed DCM before drug therapy, facilitating disease management and invasive therapy selection. A multicenter prospective study is necessary for further validation.

Clinical Trial Registration:http://www.chictr.org.cn/usercenter.aspx (ChiCTR2000034128).

A clinical score for predicting left ventricular reverse remodelling in patients with dilated cardiomyopathy

Aims

Left ventricular reverse remodelling (LVRR) is a well‐established predictor of a good prognosis in patients with dilated cardiomyopathy (DCM). The prediction of LVRR is important when developing a long‐term treatment strategy. This study aimed to assess the clinical predictors of LVRR and establish a scoring system for predicting LVRR in patients with DCM that can be used at any institution.

Methods and results

We consecutively enrolled 131 patients with DCM and assessed the clinical predictors of LVRR. LVRR was defined as an absolute increase in left ventricular ejection fraction (LVEF) from ≥10% to a final value of >35%, accompanied by a decrease in left ventricular end‐diastolic dimension (LVEDD) ≥ 10% on echocardiography at 1 ± 0.5 years after a diagnosis of DCM. The mean patient age was 50.1 ± 11.9 years. The mean LVEF was 32.2 ± 9.5%, and the mean LVEDD was 64.1 ± 12.5 mm at diagnosis. LVRR was observed in 45 patients (34%) at 1 ± 0.5 years. In a multivariate analysis, hypertension [odds ratio (OR): 6.86; P = 0.002], no family history of DCM (OR: 10.45; P = 0.037), symptom duration <90 days (OR: 6.72; P < 0.001), LVEF <35% (OR: 13.66; P < 0.0001), and QRS duration <116 ms (OR: 5.94; P = 0.005) were found to be independent predictors of LVRR. We scored the five independent predictors according to the ORs (1 point, 2 points, 1 point, 2 points, and 1 point, respectively), and the total LVRR predicting score was calculated by adding these scores. The LVRR rate was stratified by the LVRR predicting score (0–2 points: 0%; 3 points: 6.7%; 4 points: 17.4%; 5 points: 48.2%; 6 points: 79.2%; and 7 points: 100%). The cut‐off value of the LVRR predicting score was >5 in receiver‐operating characteristic curve analysis (area under the curve: 0.89; P < 0.0001; sensitivity: 87%; specificity: 78%). An LVRR predicting score of >5 was an independent predictor compared with the presence of late gadolinium enhancement on cardiovascular magnetic resonance or the severity of fibrosis on endomyocardial biopsy (OR: 11.79; 95% confidence interval: 2.40–58.00; P = 0.002).

Conclusions

The LVRR predicting score using five predictors including hypertension, no family history of DCM, symptom duration <90 days, LVEF <35%, and QRS duration <116 ms can stratify the LVRR rate in patients with DCM. The LVRR predicting score may be a useful clinical tool that can be used easily at any institution.

Assessing myocardial circumferential strain using cardiovascular magnetic resonance after magnetic resonance-conditional cardiac resynchronization therapy

Nondrug therapy for arrhythmia patients had been developed dramatically until recent years. Cardiac resynchronization therapy (CRT), a nondrug therapy for arrhythmia, is especially utilized for the treatment of left ventricular (LV) severe heart failure caused by cardiac dyssynchrony. Prolonged QRS duration (≧130 ms) is strongly used as a CRT indication criterion, but QRS is not the direct clinical index of mechanical contraction delay of the LV myocardium. Therefore, identifying the presence of dyssynchrony by diagnostic imaging is necessary. Echocardiography is widely used for the assessment of dyssynchrony as a standard diagnostic imaging. Several studies have addressed the efficacy of cardiovascular magnetic resonance feature tracking (CMR-FT) in the diagnosis of dyssynchrony for arrythmia patients. In addition, cardiac implantable electronic devices (CIEDs) were not available to examine CMR until recent years; however, new MR-conditional CIEDs have become available for use before and after CRT. Recently, diagnostic imaging using CMR-FT has been attracting attention for the assessment of dyssynchrony. However, a strong metal artifact caused by CIEDs may make the analysis difficult after CRT implantation. Strain analysis using short-axis (SA) cine CMR overcame this issue of artifact by enabling slice selection by avoiding artifact. Moreover, circumferential strain has superiority over other strain methods with respect to sensitivity, and we focused on these advantages. This case illustrates that circumferential strain with CMR-FT using SA cine CMR is useful in the assessment of improvement of myocardial motion after CRT and can provide useful additional information with imaging to determine the responders of CRT.

Imaging, Biomarker, and Clinical Predictors of Cardiac Remodeling in Heart Failure With Reduced Ejection Fraction

In response to injury, hemodynamic changes, or neurohormonal activation, the heart undergoes a series of structural and functional changes that have been termed cardiac remodeling. Remodeling is defined as changes in cardiac geometry and/or function over time and can be measured in terms of changes in cardiac chamber dimensions, wall thickness, volumes, mass, and ejection fraction at serial imaging examinations. As to cardiac chambers, left ventricular (LV) remodeling has been best studied in patients with heart failure with reduced ejection fraction. Although LV remodeling may compensate for abnormal hemodynamic parameters and function in the short term, left unchecked, it is associated with worsening cardiac function and poor prognosis. On the other hand, reversing LV geometry and/or function closer to that of a normal heart (also known as reverse remodeling) is associated with improved cardiac function and better prognosis. Because of its close relationship with clinical outcomes, remodeling may potentially be targeted in clinical management and used in trials as a surrogate endpoint. Standardized definition of remodeling and reliable tools to predict and monitor the presence, direction, and magnitude of cardiac remodeling are needed. Together with clinical and imaging findings, circulating biomarkers (most notably N-terminal pro-B-type natriuretic peptide, high-sensitivity troponin, and soluble suppression of tumorigenesis-2) may be helpful in this respect.

The Prognostic Value of Late Gadolinium-Enhanced Cardiac Magnetic Resonance Imaging in Nonischemic Dilated Cardiomyopathy: A Review and Meta-Analysis

OBJECTIVES

This review and meta-analysis reviews the prognostic value of cardiac magnetic resonance (CMR) in nonischemic dilated cardiomyopathy (DCM).

BACKGROUND

Late gadolinium-enhanced (LGE) CMR is a noninvasive method to determine the underlying cause of DCM and previous studies reported the prognostic value of the presence of LGE to identify patients at risk of major adverse cardiovascular events.

METHODS

PubMed was searched for studies describing the prognostic implication of LGE in patients with DCM for the specified endpoints cardiovascular mortality, major ventricular arrhythmic events including appropriate implantable cardioverter-defibrillator therapy, rehospitalization for heart failure, and left ventricular reverse remodeling.

RESULTS

Data from 34 studies were included, with a total of 4,554 patients. Contrast enhancement was present in 44.8% of DCM patients. Patients with LGE had increased cardiovascular mortality (odds ratio [OR]: 3.40; 95% confidence interval [CI]: 2.04 to 5.67), ventricular arrhythmic events (OR: 4.52; 95% CI: 3.41 to 5.99), and rehospitalization for heart failure (OR: 2.66; 95% CI: 1.67 to 4.24) compared with those without LGE. Moreover, the absence of LGE predicted left ventricular reverse remodeling (OR: 0.15; 95% CI: 0.06 to 0.36).

CONCLUSIONS

The presence of LGE on CMR substantially worsens prognosis for adverse cardiovascular events in DCM patients, and the absence indicates left ventricular reverse remodeling.

Extracellular volume fraction assessed using cardiovascular magnetic resonance can predict improvement in left ventricular ejection fraction in patients with dilated cardiomyopathy

T1 mapping using cardiac magnetic resonance (CMR) is useful for myocardial assessment. However, its prognostic value is not well defined. The aim of this study was to determine whether T1 mapping with CMR can predict reverse cardiac remodeling in patients with non-ischemic dilated cardiomyopathy (NIDCM). We also investigated the predictive prognostic value of T1 mapping with CMR in these patients. We included 33 patients with NIDCM admitted to Nippon Medical School Hospital between February 2012 and October 2015. All patients underwent CMR and echocardiography for clinical assessment within 1 month of admission (13 ± 16 days). Follow-up echocardiography was performed no sooner than 6 months after the initial echocardiogram (536 ± 304 days). We evaluated the correlations between native and post-contrast T1 values/extracellular volume fraction (ECV) and the difference in left ventricular ejection fraction (ΔLVEF) determined at baseline and follow-up echocardiography. No correlation was noted between ΔLVEF and native (p = 0.150, r = - 0.256) or post-contrast T1 values (p = 0.956, r = - 0.010). However, a significant and substantial correlation was found between ΔLVEF and ECV (p = 0.043, r = - 0.355). Four patients were hospitalized for heart failure (HF), but no cardiovascular-related deaths occurred over a median follow-up period of 34 months (interquartile range 25-49 months). Kaplan-Meier curves stratified by the median value of ECV were created. The higher ECV groups experienced a significantly higher incidence of HF-related hospitalization (p = 0.0159). ECV measured by CMR can predict improvements in LVEF in patients with NIDCM. In addition, ECV may be a predictive factor for HF-related hospitalization.

Multimodality imaging assessment of mitral valve anatomy in planning for mitral valve repair in secondary mitral regurgitation

Secondary mitral regurgitation (MR) is frequent valvular heart disease and conveys worse prognostic. Therapeutic surgical or percutaneous options are available in the context of severe symptomatic secondary MR, but the best approach to treat these patients remains unclear, given the lack of clear clinical evidence of benefit. A comprehensive evaluation of the mitral valve apparatus and the left ventricle (LV) has the ability to clearly define and characterize the disease, and thus determine the best option for the patient to improve its clinical outcomes, as well as quality of life and symptoms. The current report reviews the mitral valve (MV) anatomy, the underlying mechanisms associated with secondary MR, the related therapeutic options available, and finally the usefulness of a multimodality imaging approach for the planning of surgical or percutaneous mitral valve intervention.

In-hospital management and outcomes in patients with peripartum cardiomyopathy: a descriptive study using a national inpatient database in Japan

Peripartum cardiomyopathy (PPCM) is a rare but life-threatening cardiac disorder characterized by maternal systolic heart failure. Although PPCM is a major cause of maternal mortality, little is known about the acute-phase management of PPCM in real-world clinical settings. We retrospectively identified patients hospitalized with PPCM from 2007 to 2014 using the Diagnosis Procedure Combination database in Japan. We investigated patient characteristics, in-hospital examinations and treatment, and in-hospital outcomes. The study patients were 283 patients hospitalized with PPCM at 177 hospitals. The mean age was 32.7 ± 5.5 years. Of the eligible patients, 134 (47.3%) patients had a hypertensive disorder, including 48 (17.0%) patients with pre-eclampsia, and 111 (39.2%) patients were admitted to the intensive care unit or emergency center. Coronary angiography, cardiac magnetic resonance imaging, and endomyocardial biopsy were performed during hospitalization in 69 (24.4%), 42 (14.8%), and 43 (15.2%) patients, respectively. Invasive pulmonary artery pressure monitoring was used in 14 (4.9%) patients. Mechanical circulatory support was used in 13 (4.6%) patients (intra-aortic balloon pumping, n = 12; extracorporeal membrane oxygenation, n = 5; ventricular assist device, n = 0). Catecholamine therapy and phosphodiesterase-III inhibitor therapy were used in 79 (27.9%) and 13 (4.6%) patients, respectively. Prolactin blockade therapy was used in 78 (27.6%) patients. During hospitalization, four (1.4%) patients died and nine (3.2%) patients developed ventricular tachycardia or fibrillation. Two (0.7%) patients received an implantable cardioverter defibrillator, but no patient received other permanent cardiac devices. This retrospective cohort study suggests that attending physicians should be ready to provide intensive care for patients with PPCM during the acute phase.