The Medical Treatment of New-Onset Peripartum Cardiomyopathy: A Systematic Review of Prospective Studies

Peripartum cardiomyopathy: a comprehensive and contemporary review

Cardiovascular disease is a major non-communicable disease globally, with increasing prevalence, posing a significant public health challenge. It is the leading non-obstetric cause of perinatal morbidity and mortality, with a substantial number of cardiac fatalities occurring in individuals without any known pre-existing cardiovascular disease. Peripartum cardiomyopathy is a type of de novo heart failure that occurs in pregnant women in the late stages of pregnancy or following delivery. Despite extensive research, diagnosing and managing peripartum cardiomyopathy remains challenging, resulting in significant morbidity and mortality. Recent advancements and novel approaches have been made to better understand and manage peripartum cardiomyopathy, including molecular and non-molecular biomarkers, genetic predisposition and risk prediction, targeted therapies, multidisciplinary care, and improved patient education. This narrative review provides a comprehensive overview and new perspectives on peripartum cardiomyopathy, covering its epidemiology, updated pathophysiological mechanisms, diagnosis, management, and future research directions for healthcare professionals, researchers, and clinicians.

An Unusual Presentation of Peripartum Cardiomyopathy Complicated by a Pulmonary Embolism: A Case Report

Peripartum cardiomyopathy (PPCM) is a rare heart condition affecting women during pregnancy or up to five months postpartum whose incidence has been rising in recent years. It is characterized by a weakened left ventricle, which impairs the heart's ability to pump blood effectively. Although the cause remains unknown, PPCM is a crucial consideration when evaluating heart failure in women of childbearing age. In this report, we present the case of a young and healthy woman who, despite lacking any identifiable risk factors, developed symptoms of systolic heart failure while undergoing an abortion during her second pregnancy, which occurred within five months of delivering her first child. After thorough investigations, a diagnosis of PPCM was established. Her treatment took place at a tertiary hospital, with regular follow-up appointments scheduled. Unfortunately, due to non-compliance with her prescribed medications, she subsequently developed a pulmonary embolism, adding another layer of complexity to her situation. This report showcases the critical role of early recognition and swift intervention in the patient's return to stability.

Left ventricular function recovery in peripartum cardiomyopathy: a cardiovascular magnetic resonance study by myocardial T1 and T2 mapping

BACKGROUND

Peripartum cardiomyopathy (PPCM) is rare and potentially life-threatening; its etiology remains unclear. Imaging characteristics on cardiovascular magnetic resonance (CMR) and their prognostic significance have rarely been studied. We sought to determine CMR's prognostic value in PPCM by using T1 and T2 mapping techniques.

METHODS

Data from 21 PPCM patients from our CMR registry database were analyzed. The control group comprised 20 healthy age-matched females. All subjects underwent comprehensive contrast-enhanced CMR. T1 and T2 mapping using modified Look-Locker inversion recovery and T2 prep balanced steady-state free precession sequences, respectively. Ventricular size and function, late gadolinium enhancement (LGE), myocardial T1 value, extracellular volume (ECV), and T2 value were analyzed. Transthoracic echocardiography was performed at baseline and during follow-up. The recovered left ventricular ejection fraction (LVEF) was defined as LVEF ≥50% on echocardiography follow-up after at least 6 months of the diagnosis.

RESULTS

CMR imaging showed that the PPCM patients had severely impaired LVEF and right ventricular ejection fraction (LVEF: 26.8 ± 10.6%; RVEF: 33.9 ± 14.6%). LGE was seen in eight (38.1%) cases. PPCM patients had significantly higher native T1 and ECV (1345 ± 79 vs. 1212 ± 32 ms, P < 0.001; 33.9 ± 5.2% vs. 27.1 ± 3.1%, P < 0.001; respectively) and higher myocardial T2 value (42.3 ± 3.7 vs. 36.8 ± 2.3 ms, P < 0.001) than did the normal controls. After a median 2.5-year follow-up (range: 8 months-5 years), six patients required readmission for heart failure, two died, and 10 showed left ventricular function recovery. The LVEF-recovered group showed significantly lower ECV (30.7 ± 2.1% vs. 36.8 ± 5.6%, P = 0.005) and T2 (40.6 ± 3.0 vs. 43.9 ± 3.7 ms, P = 0.040) than the unrecovered group. Multivariable logistic regression analysis showed ECV (OR = 0.58 for per 1% increase, P = 0.032) was independently associated with left ventricular recovery in PPCM.

CONCLUSIONS

Compared to normal controls, PPCM patients showed significantly higher native T1, ECV, and T2. Native T1, ECV, and T2 were associated with LVEF recovery in PPCM. Furthermore, ECV could independently predict left ventricular function recovery in PPCM.

Peripartum Cardiomyopathy: Current Options for Treatment and Cardiovascular Support

Peripartum cardiomyopathy is a rare form of acute heart failure but the major cause of all deaths in pregnant patients with heart failure. Improved survival rates in recent years, however, emphasize the importance of early recognition and initiation of heart failure treatment. This article, therefore, attempts to raise awareness among cardiac and obstetric anesthesiologists as well as intensivists of this often fatal diagnosis. This review summarizes theories of the pathophysiology and outcome of peripartum cardiomyopathy. Based on the most recent literature, it further outlines diagnostic criteria and treatment options including medical management, mechanical circulatory support devices, and heart transplantation. Earlier recognition of this rare condition and a new generation of mechanical circulatory devices has contributed to the improved outcome. More frequently, patients in cardiogenic shock who fail medical management are successfully bridged to recovery on extracorporeal circulatory devices or survive with a long-lasting implantable ventricular assist device. The outcome of transplanted patients with peripartum cardiomyopathy, however, is worse compared to other recipients of heart transplants and warrants further investigation in the future.

The effect of bromocriptine on left ventricular functional recovery in peripartum cardiomyopathy: insights from the BRO-HF retrospective cohort study

Aims

Bromocriptine is thought to facilitate left ventricular (LV) recovery in peripartum cardiomyopathy (PPCM) through inhibition of prolactin secretion. However, this potential therapeutic effect remains controversial and was incompletely studied in diverse populations.

Methods and results

Consecutive women with new‐onset PPCM (n = 76) between 1994 and 2015 in Quebec, Canada, were classified according to treatment (n = 8, 11%) vs. no treatment (n = 68, 89%) with bromocriptine. We assessed LV functional recovery at mid‐term (6 months) and long‐term (last follow‐up) and compared outcomes among groups. Women treated with bromocriptine experienced better mid‐term left ventricular ejection fraction (LVEF) recovery from 23 ± 10% at baseline to 55 ± 12% at 6 months, compared with a change from 30 ± 12% at baseline to 45 ± 13% at 6 months in women treated with standard medical therapy (P interaction < 0.01). At long‐term, a similar positive association was found with bromocriptine (9% greater LVEF variation, P interaction < 0.01). In linear regressions adjusted for obstetrical, clinical, echocardiographic, and pharmacological variables, treatment with bromocriptine was associated with a greater improvement in LVEF [β coefficient (standard error), 14.1 (4.4); P = 0.03]. However, there was no significant association between bromocriptine use and the combined occurrence of all‐cause death and heart failure events (hazard ratio, 1.18; 95% confidence interval, 0.15 to 9.31), using univariable Cox regressions based over a cumulative follow‐up period of 285 patient‐years.

Conclusions

In women newly diagnosed with PPCM, treatment with bromocriptine was independently associated with greater LV functional recovery.

2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure

Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.

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.

Peripartum Cardiomyopathy

Peripartum cardiomyopathy is a potentially life-threatening pregnancy-associated disease that typically arises in the peripartum period and is marked by left ventricular dysfunction and heart failure. The disease is relatively uncommon, but its incidence is rising. Women often recover cardiac function, but long-lasting morbidity and mortality are not infrequent. Management of peripartum cardiomyopathy is largely limited to the same neurohormonal antagonists used in other forms of cardiomyopathy, and no proven disease-specific therapies exist yet. Research in the past decade has suggested that peripartum cardiomyopathy is caused by vascular dysfunction, triggered by late-gestational maternal hormones. Most recently, information has also indicated that many cases of peripartum cardiomyopathy have genetic underpinnings. We review here the known epidemiology, clinical presentation, and management of peripartum cardiomyopathy, as well as the current knowledge of the pathophysiology of the disease.