Acute and critically ill peripartum cardiomyopathy and 'bridge to' therapeutic options: a single center experience with intra-aortic balloon pump, extra corporeal membrane oxygenation and continuous-flow left ventricular assist devices

Preeclamptic heart failure - perioperative concerns and management: a narrative review

Preeclampsia is an important cause of heart failure during pregnancy and the postpartum period. The aim of this review is to elucidate the pathophysiology and clinical features of preeclamptic heart failure and describe the medical and anesthetic management of these high-risk parturients. This article reviews the current evidence base regarding preeclamptic heart failure and its pathophysiology, types, and clinical features. We also describe the medical and anesthetic management of these patients during the peripartum period. Heart failure due to preeclampsia can present as either systolic or diastolic dysfunction. The management strategies of systolic heart failure include dietary salt restriction, diuresis, and cautious use of beta-blockers and vasodilators. Diuretics are the mainstay in the treatment of diastolic heart failure. In the absence of obstetric indications, vaginal delivery is the safest mode of delivery in these high-risk patients, and the use of an early labor epidural for analgesia is recommended. These patients would require increased invasive monitoring during labor and vaginal delivery. Neuraxial and general anesthesia have been used successfully for cesarean section in these patients but require crucial modifications of the standard technique. Uterotonic drugs have significant cardiovascular and pulmonary effects, and a clear understanding of these is essential during the management of these patients. Preeclamptics with heart failure require individualized peripartum care, as cardiac decompensation is an important risk factor for maternal and neonatal morbidity and mortality. These high-risk parturients benefit from timely multidisciplinary team inputs and collaborated management.

Cardiogenic Shock and Utilization of Mechanical Circulatory Support in Pregnancy

Maternal mortality rates are rising in the United States, a trend which is in contrast to that seen in other high-income nations. Cardiovascular disease and hypertensive disorders of pregnancy are consistently the leading causes of maternal mortality both in the United States and globally, accounting for about one-quarter to one-third of maternal and peripartum deaths. A large proportion of cardiovascular morbidity and mortality stems from acquired disease in the context of cardiovascular risk factors, which include obesity, pre-existing diabetes and hypertension, and inequities in care from maternal care deserts and structural racism. Patients may also become pregnant with preexisting structural heart disease, or acquire disease throughout pregnancy (ex: spontaneous coronary artery dissection, peripartum cardiomyopathy), and be at higher risk of pregnancy-related cardiovascular complications. While risk-stratification tools including the modified World Health Organization (mWHO) classification, Cardiac Disease in Pregnancy (CARPREG II) and Zwangerschap bij Aangeboren HARtAfwijking/Pregnancy in Women with Congenital Heart Disease (ZAHARA) have been designed to help physicians identify patients at increased risk for adverse pregnancy outcomes and who may therefore benefit from referral to a tertiary care center, the limitation of these scores is their predominant focus on patients with known preexisting heart disease. As such, identifying patients at risk for pregnancy complications presents a significant challenge, and it is often patients with high-risk cardiovascular substrates prior to or during pregnancy who are at a highest risk for adverse pregnancy outcomes including cardiogenic shock.

Peripartum Cardiogenic Shock and Mechanical Circulatory Support

Despite remarkable improvements in the past two decades, the annual cardiovascular mortality rate has remained higher for women than for men. Pregnant women represent an underinvestigated population in clinical research, and the mechanisms of long-term cardiovascular complications in women with obstetric complications remain to be elucidated. Regarding advanced heart failure during pregnancy, interventional approaches are effective but still underutilised. Percutaneous mechanical circulatory support is a valuable option for peripartum cardiogenic shock, although its use during pregnancy is still limited. Survival rates have improved in recent years, but further emphasis on the importance of early recognition and initiation of heart failure treatment in this patient group is warranted. The aims of this review are to summarise the current literature on the implementation of mechanical circulatory support in cardiogenic shock during pregnancy and delivery and to understand the role of percutaneous ventricular assist devices in the management of such conditions.

Meta-Analysis of Long-Term (>1 Year) Cardiac Outcomes of Peripartum Cardiomyopathy

Peripartum cardiomyopathy is the development of heart failure toward the end of pregnancy or in the months after delivery in the absence of other attributable causes, with left ventricular systolic dysfunction and a left ventricular ejection fraction (LVEF) generally <45%. Given that patients are relatively young at the time of diagnosis, this study was performed to summarize current evidence surrounding the long-term cardiac outcomes. MEDLINE, Embase, Cochrane CENTRAL, and CINAHL were searched for original studies that reported long-term (>1 year) patient outcomes. Of the 3,144 total records identified, 62 studies involving 4,282 patients met the selection criteria. The mean LVEF was 28% at diagnosis and 47% at the time of the last follow-up. Approximately half of the patients achieved myocardial recovery (47%), most commonly defined as an LVEF >50% (n = 21). The prevalence of implantable cardioverter-defibrillator use, left ventricular assist device implantation, and heart transplantation was 12%, 7%, and 11%, respectively. The overall all-cause mortality was 9%, and despite having more cardiovascular risk factors, patients residing in high-income countries had superior outcomes, including reduced rates of mortality.

Contemporary Management of Cardiogenic Shock During Pregnancy

Cardiogenic shock is the most extreme cardiovascular disease state during pregnancy. Peripartum cardiomyopathy is the most common cause of cardiogenic shock toward the end of pregnancy and in the early postpartum period. Therapy for cardiogenic shock relies on appropriate phenotyping of shock etiology, severity and ventricular predominance, which are critical in the appropriate selection of medical and mechanical therapy. Mechanical circulatory support may be used as a bridge to recovery or as definitive therapy. Intra-aortic balloon pumps, percutaneous left ventricular assist devices and venoarterial extracorporeal circulatory devices have been successfully used in pregnancy and the postpartum period. The most commonly used mechanical therapy in the pregnant patient is extracorporeal membranous oxygenation circulatory support. The use of mechanical circulatory devices in peripartum cardiomyopathy has contributed to improved survival rates in recent years. Further efforts to identify the optimal mechanical circulatory support strategy for peripartum cardiomyopathy and cardiogenic shock in the peripartum period are needed.

A Detailed Review of Critical Care Considerations for the Pregnant Cardiac Patient

Maternal cardiovascular disease is a leading cause of maternal death worldwide and recently, maternal mortality has increased secondary to cardiovascular causes. Maternal admissions to critical care encompass 1%-2% of all critical care admissions, and although not common, the management of the critically ill pregnant patient is complex. Caring for the critically ill pregnant cardiac patient requires integration of pregnancy-associated physiologic changes, understanding pathophysiologic disease states unique to pregnancy, and a multidisciplinary approach to timing around delivery as well as antenatal and postpartum care. Herein we describe cardiorespiratory changes that occur during pregnancy and the differential diagnosis for cardiorespiratory failure in pregnancy. Cardiorespiratory diseases that are either associated or exacerbated by pregnancy are highlighted with emphasis on perturbations secondary to pregnancy and appropriate management strategies. Finally, we describe general management of the pregnant cardiac patient admitted to critical care.

Peripartum Cardiomyopathy Incidence, Risk Factors, Diagnostic Criteria, Pathophysiology, and Treatment Options

Peripartum cardiomyopathy is a rare and a severe form of heart failure that affects women during pregnancy or shortly after delivery. Risk factors include advanced age, race, multiparity, multifetal pregnancy, socioeconomic disparity, and medical comorbidities including systemic hypertension, diabetes, asthma, and anemia. Peripartum cardiomyopathy is associated with increased morbidity and mortality, as well as a detrimental long-term impact on quality of life. Its etiology is not clear, although it is thought to be a combined effect of a hyperdynamic fluid state associated with pregnancy, hormonal changes unique to gestation, and a genetic predisposition. There is no current expert consensus on an optimal treatment regimen. This article will provide a comprehensive review and update on this important disease state.

Interventional Cardiology and Catheter-Based Interventions in Pregnancy

Cardiovascular disease is the leading cause of maternal mortality worldwide and has been increasing in prevalence over the last several decades. Pregnancy is associated with significant hemodynamic changes that can overwhelm the maternal cardiovascular reserve, and may exacerbate previously asymptomatic cardiovascular disease. Complications associated with these may cause substantial harm to both the mother and the fetus, and the management of these conditions is often challenging. Numerous novel treatments and interventions have demonstrated the safety and efficacy of managing these conditions outside of pregnancy. However, there are little data regarding their use in the pregnant population. In this review, we describe the common cardiovascular diseases encountered during pregnancy and discuss their management strategies, with a particular focus on the role of percutaneous, catheter-based therapeutic interventions.

Mechanical Circulatory Support in Women

A number of devices can now provide mechanical circulatory support (MCS) to patients with acute cardiogenic shock (CS) and chronic end-stage heart failure (HF). Women differ from men in pathophysiology and natural history of CS and HF, and are usually sicker at admission. Current evidence suggests that women benefit as much as men, if not more, from both temporary and durable MCS for appropriate indications. Yet, women have been under-represented in clinical trials of MCS devices. Limited evidence suggests that women benefit more from temporary MCS in CS associated with acute myocardial infarction. However, in patients with durable left ventricular assist devices (LVADs), women are more likely to experience thromboembolic events and right HF. This review aims to study available evidence and determine areas for further research on gender differences in (a) use of temporary MCS for CS and (b) use of durable LVADs. Use of MCS in conditions specific to, or more common in women (pregnancy, takotsubo cardiomyopathy, peripartum cardiomyopathy, and spontaneous coronary artery dissection) is also discussed.

Extracorporeal Life Support in Pregnancy: A Systematic Review

Background The use of extracorporeal life support (ECLS) has expanded to include unique populations such as peripartum women. This systematic review aims to (1) quantify the number of cases and indications for ECLS in women during the peripartum period reported in the literature and (2) report maternal and fetal complications and outcomes associated with peripartum ECLS. Methods and Results This review was registered in PROSPERO (CRD42018108142). MEDLINE, Embase, and CINAHL were searched for case reports, case series, and studies reporting cases of ECLS during the peripartum period that reported one or more of the following outcomes: maternal survival, maternal complications, fetal survival, and/or fetal complications. Qualitative assessment of 221 publications evaluated the number of cases, clinical details, and maternal and fetal outcomes of ECLS during the peripartum period. There were 358 women included and 68 reported fetal outcomes in cases where the mother was pregnant at the time of cannulation. The aggregate maternal survival at 30 days was 270 (75.4%) and at 1 year was 266 (74.3%); fetal survival was 44 (64.7%). The most common indications for ECLS overall in pregnancy included acute respiratory distress syndrome 177 (49.4%), cardiac failure 67 (18.7%), and cardiac arrest 57 (15.9%). The most common maternal complications included mild to moderate bleeding 66 (18.4%), severe bleeding requiring surgical intervention 48 (13.4%), and intracranial neurologic morbidity 19 (5.3%). The most commonly reported fetal complications included preterm delivery 33 (48.5%) and neonatal intensive care unit admission 19 (27.9%). Conclusions Reported rates of survival in ECLS in pregnant and postpartum women are high and major complications relatively low.

Anthracycline and Peripartum Cardiomyopathies

Anthracycline-associated cardiomyopathy and peripartum cardiomyopathy are nonischemic cardiomyopathies that often afflict previously healthy young patients; both diseases have been well described since at least the 1970s and both occur in the settings of predictable stressors (ie, cancer treatment and pregnancy). Despite this, the precise mechanisms and the ability to reliably predict who exactly will go on to develop cardiomyopathy and heart failure in the face of anthracycline exposure or childbirth have proven elusive. For both cardiomyopathies, recent advances in basic and molecular sciences have illuminated the complex balance between cardiomyocyte and endothelial homeostasis via 3 broad pathways: reactive oxidative stress, interference in apoptosis/growth/metabolism, and angiogenic imbalance. These advances have already shown potential for specific, disease-altering therapies, and as our mechanistic knowledge continues to evolve, further clinical successes are expected to follow.

Extracorporeal membrane oxygenation in peripartum cardiomyopathy: A review of the ELSO Registry

AIMS

Data on the use of extracorporeal membrane oxygenation (ECMO) for cardiogenic shock in peripartum cardiomyopathy (PPCM) is limited. We queried the Extracorporeal Life Support Organization (ELSO) Registry for PPCM patients treated with ECMO in order to characterize demographic and clinical features, complications, survival, and variables associated with mortality.

METHODS AND RESULTS

This was a retrospective review of patients voluntarily entered into the ELSO Registry. De-identified data was collected on patients with a diagnosis of PPCM based on ICD-9/ICD-10 coding who received ECMO between 2007 and 2019. Collected data included demographics, ECMO mode, cannulation strategies, pre-ECMO ventilator, biochemical, and hemodynamic parameters, run duration, complications, and survival to wean off ECMO and hospital discharge. Our primary outcome measure was survival to discharge. In the final analysis, 88 veno-arterial (VA) ECMO patients were included. Overall, 72% of patients were weaned off ECMO, including 10% who were weaned to ventricular assist device or heart transplantation, and 64% survived to hospital discharge. Extracorporeal cardiopulmonary resuscitation (ECPR) was performed in 11% of patients with 60% survival. Factors associated with decreased survival included neurologic complications (p = 0.03), specifically central nervous system hemorrhage (p = 0.01).

CONCLUSION

Our review is the largest to date of PPCM patients supported with VA ECMO for cardiogenic shock. ECMO and ECPR are valuable forms of short-term mechanical circulatory support with acceptable mortality profiles for PPCM patients who remain refractory to aggressive medical management. Complications should be meticulously avoided, especially neurologic complications.

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.

A Case Report of Recurrent Severe Peripartum Cardiomyopathy Complicated by Factor V Leiden and Multiple Endocrine Neoplasia Type 1: A Management Conundrum

Cardiovascular disease is the leading cause of peripartum death in the United States during pregnancy. The presence of concomitant diagnoses may complicate or conflict with the management of the primary cardiovascular diagnosis and further complicate pregnancy and delivery. We describe the management of a 29-year-old, gravida 5, para 1 woman with severe peripartum cardiomyopathy during this and a previous pregnancy complicated by multiple endocrine neoplasia type and factor V Leiden thrombophilia, limiting therapeutic options and contributing to considerable perioperative management challenges.

Emergent caesarean section under mechanical circulatory support for acute severe peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is an idiopathic left ventricular dysfunction in women who are in late pregnancy or the postpartum period. PPCM is a rare but sometimes fatal disease, and mechanical circulatory support is required if heart failure is refractory to conventional therapy. A 28-year-old woman in late pregnancy was admitted to our hospital due to congestive heart failure with cardiogenic shock. Her heart rate was 200 beats per minute (sinus tachycardia), and left ventricular ejection fraction (LVEF) was 10%. Additionally, fetal heart rate decreased to 80 beats per minute. It was extremely difficult to continue her pregnancy because of decompensated heart failure and fetal asphyxia; therefore, we delivered her baby via caesarean section after initiating mechanical circulatory support. With optimal medical therapy, including bromocriptine, we were able to remove mechanical circulatory support. Additionally, LVEF improved to 42%, and she was discharged with her baby who had no growth failure. This case highlights the safety and risk of caesarean section under mechanical circulatory support, and the effectiveness of bromocriptine. <Learning objective: Mechanical circulatory support is occasionally required if heart failure is refractory to conventional medical therapy in peripartum cardiomyopathy (PPCM). Mechanical circulatory support, particularly extracorporeal membrane oxygenation needing sufficient anticoagulation, should be initiated following delivery via caesarean section because of bleeding from the uterus. Moreover, bromocriptine may be effective in improving PPCM and should be the first-line treatment in clinical practice.>.

Heart Transplantation for Peripartum Cardiomyopathy: A Single-Center Experience

Background

Peripartum cardiomyopathy is an idiopathic disorder defined by the occurrence of acute heart failure during late pregnancy or post-partum period in the absence of any other definable cause. Its clinical course is variable and severe cases might require heart transplantation.

Objective

To investigate long-term outcomes after heart transplantation (HT) for peripartum cardiomyopathy (PPCM).

Methods

Out of a single-center series of 1938 HT, 14 HT were performed for PPCM. We evaluated clinical characteristics, transplant-related complications, and long-term outcomes, in comparison with 28 sex-matched controls. Primary endpoint was death from any cause; secondary endpoints were transplant-related complications (rejection, infection, cardiac allograft vasculopathy). A value of p < 0.05 was considered of statistical significance.

Results

PPCM patients and matched controls were comparable for most variables (all p values > 0.05), except for a higher use of inotropes at the time of HT in PPCM group (p = 0.03). During a median follow-up of 7.7 years, 16 patients died, 3 (21.5%) in PPCM group and 13 (46.5%) in control group. Mortality was significantly lower in PPCM group (p = 0.03). No significant difference was found in terms of transplant-related complications (p > 0.05).

Conclusions

Long-term outcomes following HT for PPCM are favorable. Heart transplantation is a valuable option for PPCM patients who did not recover significantly under medical treatment.

First-Line Support by Intra-Aortic Balloon Pump in Non-Ischaemic Cardiogenic Shock in the Era of Modern Ventricular Assist Devices

OBJECTIVES

Little is known about circulatory support in cardiogenic shock (CS) from other causes than the acute coronary syndrome or after cardiotomy. We evaluated the effects of first-line intra-aortic balloon pump (IABP) support in this subpopulation of CS patients.

METHODS

A retrospective study was performed in 27 patients with CS from end-stage cardiomyopathy supported firstly by IABP in the years 2011-2016.

RESULTS

At 24 h, lactate decreased from 3.2 (2.1-6.8) to 1.8 (1.2-2.2) mmol/L (p < 0.001). Eighteen patients (67%) defined as IABP responders were successfully bridged to either recovery (n = 7), left ventricular assist device (n = 5), or heart transplantation (n = 6). IABP failed in 9 patients (non-responders, 33%) who either died (n = 7) or needed support by extracorporeal membrane oxygenation (n = 2). At 24 h of IABP support, urinary output was higher (2,660 [1,835-4,440] vs. 1,200 [649-2,385] mL; p = 0.02) and fluid balance more negative (-1,564 [-2,673 to -1,086] vs. -500 [-930 to +240] mL; p < 0.001) in responders than non-responders. Overall survival at 1 year was 63%.

CONCLUSION

In most patients, first-line support by IABP in end-stage cardiomyopathy is associated with improvement in organ perfusion and clinical stabilisation for at least 24 h allowing time for decision making on next therapies.

Management of pregnancy in cardiomyopathies and heart failure

Pregnancy exposes women with inherited cardiomyopathies to increased risk for arrhythmias and heart failure. In asymptomatic patients with inherited cardiomyopathies, pregnancy is generally well tolerated. Preconception evaluation, risk assessment and proper counseling by a team of experienced physicians are mandatory in managing women with inherited cardiomyopathies planning pregnancy. In this paper, we reviewed the clinical course, risk assessment and management during pregnancy of women with cardiomyopathies.

Veno-venous ECMO as a safe bridge to recovery in a patient with severe peripartum cardiomyopathy – learning from errors

Peripartum cardiomyopathy (PPCM) is a rare disorder of unknown etiology and pathogenesis. The most important tool for diagnostic confirmation is transthoracic echocardiography. The recommended management of PPCM in pregnancy is summarized by the European Society of Cardiology Heart Failure Guidelines. Few data exist on the treatment of patients with fulminant PPCM and the need for extracorporeal membrane oxygenation (ECMO) in this context. We report on a young multiparous woman with cardiogenic shock caused by severe PPCM who was successfully, but atypically, supported with veno-venous ECMO as a bridge to recovery immediately after the birth of her third child.

Peripartum cardiomyopathy, place of drug therapy, assist devices, and outcome after left ventricular assistance

Peripartum cardiomyopathy remains a challenging obstetric and cardiologic emergency. We report 5 interesting cases of peripartum cardiomyopathy with different clinical courses, with 3 patients requiring left ventricular assist device implantation. One patient underwent pump explantation and aortic balloon valvuloplasty postsurgery. Two patients improved with the medical treatment alone without the need of assistance. We will review main important related issues.

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.

Management of Complex Cardiac Issues in the Pregnant Patient

Management of peripartum heart disease in the intensive care unit requires optimization of maternal hemodynamics and maintenance of fetal perfusion. This requires fetal monitoring and should address the parturient's oxygen saturation, hemoglobin, and cardiac output as it relates to uterine blood flow. Pharmacologic strategies have limited evidence pertaining to hemodynamic stabilization and fetal perfusion. There is some evidence that surgical management of critical mitral stenosis should be percutaneous when possible because cardiac bypass is associated with increased fetal mortality. Fetal monitoring strategies should address central organ perfusion because peripheral scalp pH has not been associated with improved fetal outcomes.

Current knowledge and recent development on management of peripartum cardiomyopathy

Heart failure with left ventricular dysfunction occurring during pregnancy or during the post-partum period in patients without history of cardiovascular disease defines peripartum cardiomyopathy (PPCM). PPCM carries a high morbidity and mortality rate as well as the possibility of recovery ad integrum. Its incidence shows ethnic variations, with a greater prevalence of the disease among women with African descent. Pathogenesis of PPCM remains poorly understood. Both "oxidative stress-prolactin axis" and "anti-angiogenic-signaling excess" hypotheses are currently being investigated. Novel diagnostic strategies and biomarkers are currently being evaluated. Besides conventional treatment of heart failure, targeted therapies such as pharmacological prolactin blockade are under evaluation. The aim of this short review is to highlight current management as targeted therapy has far been disappointing.

Critical care in pregnancy--is it different?

In the first part of this review, the epidemiology of obstetric critical care is discussed. This includes the incidence of severe morbidity in pregnancy, identification of critically ill and potentially critically ill patients, the incidence of obstetric ICU admissions, the type of critical illness by stage of pregnancy, ICU admission diagnoses, the severity of illness in obstetric ICU patients compared to non-obstetric patients, ICU mortality of obstetric patients, the ICU proportion of total maternal mortality, and the causes of death for obstetric patients in ICU. In the second part, the management of obstetric patients who happen to be admitted to a general ICU is discussed. Rather than focusing on the management of particular obstetric conditions, general principles of ICU management will be discussed as applied to obstetric ICU patients. These include drug safety, monitoring the fetus, management of the airway, sedation, muscle relaxation, ventilation, cardiovascular support, thromboprophylaxis, and radiology and ethical issues.

An update on treatments and outcomes in peripartum cardiomyopathy

ABSTRACT: 

Peripartum cardiomyopathy (PPCM) is a well-established complication of pregnancy. Criteria include heart failure that presents with reduced left ventricular function, signs and symptoms of heart failure either late in pregnancy or early in the postpartum period. The incidence varies widely depending geography and ethnicity. The pathophysiology of PPCM is still an area of active investigation, but includes immune and inflammatory mechanisms, which are the subject of several investigations. Therapies for chronic heart failure from PPCM are similar to those patients with nonischemic cardiomyopathy from different etiologies, however novel therapies may include bromocriptine, pentoxifylline or other potential therapies influencing the immune system. The need for implantable defibrillators, left ventricular assist devices and cardiac transplant in women with PPCM is rare, and prognosis is better than other forms of nonischemic cardiomyopathy. Despite this, further information about the epidemiology, prognosis and potential therapies are required to better manage and diagnose PPCM in women with signs and symptoms of heart failure.

Development of takotsubo cardiomyopathy with severe pulmonary edema before a cesarean section

Takotsubo cardiomyopathy is an acute syndrome involving apical ballooning and consequent dysfunction of the left ventricle. Most cases of left ventricular dysfunction resolve within 1 month. We present the case of a 40-year-old woman who developed severe heart failure caused by takotsubo cardiomyopathy with severe left ventricular dysfunction during the perinatal period. Because of the presence of multiple myomas, she was scheduled to undergo a cesarean section under general anesthesia. However, after induction of general anesthesia, she had to be awakened because of the presence of a difficult airway. Because she exhibited insufficient oxygenation, she was transferred to the emergency center. Upon hospital admission, she expectorated large amounts of pink sputum, indicating severe pulmonary edema. Cesarean section was performed immediately. Echocardiography revealed severe left ventricular dysfunction. Full recovery of cardiac function required almost 1 month, after which she was discharged from the hospital without further complications. This is the first reported case of takotsubo cardiomyopathy induced by a failed intubation during a scheduled cesarean section. Takotsubo cardiomyopathy usually shows a good prognosis, but if this myopathy develops during the perinatal period, it can worsen because of excessive preload following the termination of fetoplacental circulation.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare form of unexplained cardiac failure of unknown origin, unique to the pregnant woman with highly variable outcome associated with high morbidity and mortality. PPCM is fraught with controversies in its definition, epidemiology, pathophysiology, diagnosis and management. PPCM is frequently under diagnosed, inadequately treated and without a laid down follow-up regimen, thus, the aim of this review. Publications on PPCM were accessed using Medline, Google scholar and Pubmed databases. Relevant materials on PPCM, selected references from internet services, journals, textbooks, and lecture notes on PPCM were also accessed and critically reviewed. PPCM is multifactorial in origin. It is a diagnosis of exclusion and should be based on classic echocardiographic criteria. The outcome of PPCM is also highly variable with high morbidity and mortality rates. Future pregnancies are not recommended in women with persistent ventricular dysfunction because the heart cannot tolerate increased cardiovascular workload associated with the pregnancy. Although, multiparity is associated with PPCM, there is an increased risk of fetal prematurity and fetal loss. PPCM is a rare form of dilated cardiomyopathy of unknown origin, unique to pregnant women. The pathophysiology is poorly understood. Echocardiography is central to diagnosis of PPCM and effective treatment monitoring in patients of PPCM. The outcome is highly variable and related to reversal of ventricular dysfunction.

[Peripartum cardiomyopathy: interdisciplinary challenge]

Peripartum cardiomyopathy (PPCM) is a rare type of heart failure which presents towards the end of pregnancy or in the first 5 months after delivery. Depending on the geographical location the incidence is reported in the literature as 1:300 up to 1:15,000. There are a number of known risk factors, such as multiparity and age of the mother over 30 years. The symptoms of PPCM correspond to those of idiopathic cardiomyopathy. The diagnosis is mainly carried out using echocardiography which shows a clear reduction of systolic left ventricular function. The therapeutic approach is the same as for idiopathic cardiomyopathy and in this context it is absolutely necessary to show caution concerning the state of pregnancy and the resulting contraindications for therapeutic drugs. The prognosis is dependent on recovery from the heart failure during the first 6 months postpartum. The lethality of the disease is high and is given in the literature as up to 28 %. Because of its complexity PPCM is an interdisciplinary challenge. In the peripartum phase a close cooperation between the disciplines of cardiology, cardiac surgery, neonatology, obstetrics and anesthesiology is indispensable. For anesthesiology the most important aspects are the mostly advanced unstable hemodynamic condition of the mother and the planning and implementation of the perioperative management. This article presents the case of a patient in advanced pregnancy with signs of acute severe heart failure and a suspected diagnosis of PPCM. The patient presented as an emergency case and delivery of the child was carried out using peridural anesthesia with a stand-by life support machine.

Peripartum cardiomyopathy: a review

Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy of unclear etiology affecting women without preexisting heart disease during the last month of pregnancy or during the first 5 months postpartum. Its incidence shows marked geographic and ethnic variation, being most common in Africa and among women of African descent. Most women present in the first month postpartum with typical heart failure symptoms such as dyspnea, lower extremity edema, and fatigue. These symptoms are often initially erroneously diagnosed as part of the normal puerperal process. Diagnosis can be aided by the finding of a significantly elevated serum brain natriuretic peptide. The etiology of PPCM is unclear; however, recent research suggests abnormal prolactin metabolism is seminal in its development, and prolactin antagonism with bromocriptine shows promise as a novel treatment for PPCM.