[Peripartum idiopathic myocardiopathy: prospective echocardiographic study]

Peripartum cardiomyopathy: basic mechanisms and hope for new therapies

Peripartum cardiomyopathy (PPCM) is a life-threatening cardiomyopathy characterized by acute or slow progression of left ventricular (LV) systolic dysfunction (LV ejection fraction of <45%) late in pregnancy, during delivery, or in the first postpartum months, in women with no other identifiable causes of heart failure. PPCM patients display variable phenotypes and risk factor profiles, pointing to involvement of multiple mechanisms in the pathogenesis of the disease. The higher risk for PPCM in women with African ancestry, the prevalence of gene variants associated with cardiomyopathies, and the high variability in onset and disease progression in PPCM patients also indicate multiple mechanisms at work. Experimental data have shown that different factors can induce and drive PPCM, including inflammation and immunity, pregnancy hormone impairment, catecholamine stress, defective cAMP-PKA, and G-protein-coupled-receptor signalling, and genetic variants. However, several of these mechanisms may merge into a common major pathway, which includes unbalanced oxidative stress and the cleavage of the nursing hormone prolactin (PRL) into an angiostatic, pro-apoptotic, and pro-inflammatory 16 kDa-PRL fragment, resulting in subsequent vascular damage and heart failure. Based on this common pathway, potential disease-specific biomarkers and therapies have emerged. Despite commonalities, the variation in aetiology and mechanisms poses challenges for the diagnosis, treatment, and management of the disease. This review summarizes current knowledge on the clinical presentation of PPCM in the context of recent experimental research. It discusses the challenge to develop disease-specific biomarkers in the context of rapid changing physiology in the peripartum phase, and outlines possible future treatment and management strategies for PPCM patients.

[Young heart failure: epidemiological, clinical and etiological aspects in the teaching hospital Sylvanus Olympio of Lomé]

AIMS

The aim of the study was to analyze the epidemiologic, clinical and etiologic aspects of heart failures of the young age to 18 to 45 years.

PATIENTS AND METHOD

It consisted of a cross-sectional study realized in hospitalization in the service of cardiologic of Teaching Hospital Sylvanus Olympio of Lomé on 35 months (January 2009 to November 2012). The completion of a Doppler echocardiography was necessary to include the patients in the study.

RESULTS

The prevalence heart failure in the 45 years old young people to more was of 28.6%. The median age of the patients was of 36.5±3 years with a sex ratio of 10.7. Heart failure was total among 268 patients (71.3%). The electrocardiogram found 88 patients (23.4%) in complete arrhythmia by auricular fibrillation. Cardiac echography found a dilation of the left ventricle among 271 patients (72.1%), a systolic dysfunction of left ventricle among 213 patients (56.6%) and an intracavitary thrombus among 37 patients (9.8%). The etiologies were: hypertension 161 cases (42.8%), heart valve diseases 68 cases (18.1%), the peripartum cardiomyopathy 58 cases (15.4%), dilated cardiomyopathy 22 cases (5.8%), the alcoholism 12 cases (3.1%), ischaemic heart diseases 10 cases (2.7%), congenital heart diseases 10 cases (2.7%), the chronic pulmonary heart 8 cases (2.1%), the cardiothyreosis 7 cases (1.8%), the pericardial tamponnade 4 cases (1.1%) and myocarditis with VIH 4 cases (1.1%). Hospital lethality was of 16.4% (62 patients).

CONCLUSION

Heart failure is a serious and frequent pathology in Africa. It affects young and active subjects. The causes are dominated by hypertension.

[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.