Genetic and Phenotypic Landscape of Peripartum Cardiomyopathy

BACKGROUND

Peripartum cardiomyopathy (PPCM) occurs in ≈1:2000 deliveries in the United States and worldwide. The genetic underpinnings of PPCM remain poorly defined. Approximately 10% of women with PPCM harbor truncating variants in TTN (TTNtvs). Whether mutations in other genes can predispose to PPCM is not known. It is also not known if the presence of TTNtvs predicts clinical presentation or outcomes. Nor is it known if the prevalence of TTNtvs differs in women with PPCM and preeclampsia, the strongest risk factor for PPCM.

METHODS

Women with PPCM were retrospectively identified from several US and international academic centers, and clinical information and DNA samples were acquired. Next-generation sequencing was performed on 67 genes, including TTN, and evaluated for burden of truncating and missense variants. The impact of TTNtvs on the severity of clinical presentation, and on clinical outcomes, was evaluated.

RESULTS

Four hundred sixty-nine women met inclusion criteria. Of the women with PPCM, 10.4% bore TTNtvs (odds ratio=9.4 compared with 1.2% in the reference population; Bonferroni-corrected P [P*]=1.2×10-46). We additionally identified overrepresentation of truncating variants in FLNC (odds ratio=24.8, P*=7.0×10-8), DSP (odds ratio=14.9, P*=1.0×10-8), and BAG3 (odds ratio=53.1, P*=0.02), genes not previously associated with PPCM. This profile is highly similar to that found in nonischemic dilated cardiomyopathy. Women with TTNtvs had lower left ventricular ejection fraction on presentation than did women without TTNtvs (23.5% versus 29%, P=2.5×10-4), but did not differ significantly in timing of presentation after delivery, in prevalence of preeclampsia, or in rates of clinical recovery.

CONCLUSIONS

This study provides the first extensive genetic and phenotypic landscape of PPCM and demonstrates that predisposition to heart failure is an important risk factor for PPCM. The work reveals a degree of genetic similarity between PPCM and dilated cardiomyopathy, suggesting that gene-specific therapeutic approaches being developed for dilated cardiomyopathy may also apply to PPCM, and that approaches to genetic testing in PPCM should mirror those taken in dilated cardiomyopathy. Last, the clarification of genotype/phenotype associations has important implications for genetic counseling.

Maternal and fetal outcomes in pregnancy complicated with Eisenmenger syndrome

OBJECTIVE

The goal of the study was to clarify the risk factors for pregnancy complicated with Eisenmenger syndrome (ES).

MATERIALS AND METHODS

A retrospective study was performed in 15 patients with ES who were managed throughout pregnancy at one institution from 1982 to 2013. Cases associated with congenital heart diseases other than atrial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) were excluded.

RESULTS

The congenital heart diseases in ES included ASD (n = 3), VSD (n = 9), and PDA (n = 3). Ten women chose termination and 5 continued with their pregnancies. In the 5 continuation cases (PDA 1, VSD 4), worsening of cyanosis, exertional fatigue and dyspnea appeared between 25 and 30 weeks gestation and cesarean section was performed at 30 (28-33) weeks. LVEF, PaO₂, and SpO₂ decreased and heart rate increased significantly from before pregnancy to 25-30 weeks gestation. From before to during the pregnancy, there were no significant changes in mean PABP or pulmonary vascular resistance (PVR) in four cases with data (582-592, 885 to 868, 1280 to 1291, 1476-1522 dyn × s/cm²). PVR at conception had a negative relationship with delivery weeks. NYHA classes before, during and 1 year after pregnancy were II, III and II. In one recent case, epoprostenol and tadalafil were administered during pregnancy.

CONCLUSIONS

Pregnancy with ES has a high risk due to hypooxygenation, cyanosis, and cardiac failure, which can appear as common complications as early as the 2nd trimester. Early interventions with meticulous care are required for these complications during pregnancy and delivery.

Peripartum Serial Echocardiographic Findings in a Patient with Life-threatening Peripartum Cardiomyopathy

A 35-year-old woman was referred to our hospital for the management of acutely decompensated heart failure due to peripartum cardiomyopathy (PPCM). Generally, cardiac examinations are performed after the manifestation of heart failure in patients with PPCM. Thus, reports of serial cardiac examinations before the onset of PPCM are scarce. In this case, we were able to document the serial echocardiographic findings before the onset of life-threatening PPCM. We found that the left ventricular systolic function was preserved at 35 weeks of gestation but declined acutely after delivery at 38 weeks. Although speculative, these findings suggest that left ventricular dilation might precede the onset of PPCM.

Effect of epidural anesthesia in labor; pregnancy with cardiovascular disease

OBJECTIVE

We studied the effect and safety of epidural anesthesia during labor in pregnant women with cardiovascular disease.

MATERIALS AND METHODS

In the pregnant women with cardiovascular disease, we compared maternal outcome and suppressive effect on blood pressure retrospectively between the epidural group (anesthetized epidurally during labor) and the no-epidural group (not anesthetized epidurally during labor).

RESULTS

A total of 277 patients were included in the analyses. Cardiovascular events decreased significantly in epidural group (P < 0.05). Cardiovascular events occurred in 12 (epidural group) and 2 (no-epidural group) of cases (P < 0.05). Cardiovascular events are all events related to arrhythmia. In the epidural group, the systolic blood pressure showed no increase in labor (110.5 mmHg, 95% CI; 95-132 mmHg vs. 110 mmHg, 95% CI; 91-130 mmHg). In the no-epidural group, the systolic blood pressure increased in labor (107 1 mmHg, 95% CI; 96-138 mmHg vs. 123 mmHg, 95% CI; 105-153 mmHg; P < 0.05).

CONCLUSION

Epidural anesthesia had decrease of the cardiovascular events related to arrhythmia and the effect of significantly suppression raising the blood pressure during labor in pregnant women with cardiovascular disease. In pregnant women with the cardiovascular disease, epidural anesthesia during labor may be available.

Cardiovascular events in pregnancy with hypertrophic cardiomyopathy

BACKGROUND

The influence of the physiological circulatory changes during pregnancy on hypertrophic cardiomyopathy (HCM) is unclear. There have been no comprehensive studies of pregnant women with HCM in the Japanese population.

METHODS AND RESULTS

A total of 27 pregnancies (23 women with HCM) were retrospectively reviewed. A total of 18 cardiovascular events occurred in 13 of the 27 pregnancies (48%), and 13 of these events (76%) were related to arrhythmia. The cardiovascular events tended to occur in the early stage of pregnancy (≈30 gestational weeks) or postpartum. The events related to arrhythmia mainly occurred in the early stage of pregnancy or at approximately 30 gestational weeks. Four pregnancies were terminated because of cardiovascular events. Cardiovascular events occurred in 8 of 9 pregnancies in women on medication before pregnancy (88%), 7 of 10 pregnancies with high CARPREG score (70%), and in 9 of 12 pregnancies with high ZAHARA score (75%).

CONCLUSIONS

Cardiovascular events occurred in more than half of the pregnant women complicated with HCM, and the arrhythmia is the most common cardiovascular event. Medication in the pre-pregnancy period, and CARPREG or ZAHARA score ≥1 were identified as risk factors of cardiac events during pregnancy or postpartum.

Risk factors for maternal and fetal outcome in pregnancy complicated by Ebstein anomaly

OBJECTIVE

The goal of the study was to examine risks in pregnancy in patients with Ebstein anomaly.

STUDY DESIGN

Data were examined retrospectively for 13 patients (27 pregnancies, 21 live births) with Ebstein anomaly during pregnancy who were treated at our institution from 1985 to 2011. The associated anomalies in these patients were atrial septal defect (ASD) (n = 4) and the Wolff-Parkinson-White syndrome (n = 6).

RESULTS

Before pregnancy, 2 patients underwent ASD closure and 1 received tricuspid valve replacement (TVR). In all patients, the cardiothoracic ratio increased from 55.1 at conception to 57.0 during pregnancy and 58.0 postpartum (P < .05). Cesarean sections were performed in 3 cases: 1 with ventricular tachycardia and orthopnea (New York Heart Association [NYHA] III) preterm; at full term, and the third in a patient with a mechanical tricuspid valve who developed maternal cerebellum hemorrhage at 27 weeks. The baby died of prematurity in the third case. In all other cases (20 of 21), neonatal prognoses were good without congenital heart diseases. There were 6 spontaneous abortions. Recurrent paroxysmal supraventricular tachycardia occurred during pregnancy in 2 cases and was treated with adenosine triphosphate or verapamil. In 17 pregnancies, NYHA remained in class I and all had full-term vaginal delivery.

CONCLUSION

Maternal and fetal outcomes are good in patients with Ebstein anomaly and NYHA class I. However, pregnancy in Ebstein anomaly can be complicated with tachyarrhythmia or cardiac failure. In post-TVR cases, meticulous care is required for these complications during pregnancy and delivery.

Cardiopulmonary variables during exercise predict pregnancy outcome in women with congenital heart disease

BACKGROUND

Maternal New York Heart Association (NYHA) class is associated with pregnancy outcome in women with congenital heart disease (WCHD), but objective predictive criteria of exercise capacity have not been established.

METHODS AND RESULTS

A total of 33 WCHD (age, 28 ± 5 years; NYHA class, 1.3 ± 0.6) who had undergone cardiopulmonary exercise testing (CPX) 1.8 ± 2.2 years before their delivery were retrospectively identified. Maternal, cardiac, and neonatal events occurred in 8 (24%), 12 (36%), and 14 (42%), respectively. All CPX parameters correlated with neonatal birth weight (P<0.05-0.001). Exercise time, peak heart rate (HR), peak systolic blood pressure, and peak oxygen uptake (VO(2)) were associated with cardiac events (P<0.05-0.01), and exercise time and peak VO(2) were also associated with neonatal events (P<0.05). Exercise time, peak HR, and peak VO(2) were associated with at least 1 of the 3 events (P<0.05-0.01). Receiver operating characteristic analysis showed that peak HR <150 beats/min and/or peak VO(2) <22.0 ml · kg(-1) · min(-1), peak VO(2) <26.2 ml · kg(-1) · min(-1), and peak HR <150 beats/min and/or peak VO(2) <25.3 ml · kg(-1) · min(-1) predicted a high probability of maternal cardiac, neonatal, and maternal cardiac and/or neonatal event, respectively.

CONCLUSIONS

CPX parameters predict pregnancy outcome and peak HR ≥ 150 beats/min and/or peak VO(2) ≥ 25 ml · kg(-1) · min(-1) may be reference value(s) for a safer pregnancy outcome in WCHD.

Risk factors for maternal outcome in pregnancy complicated with dilated cardiomyopathy

OBJECTIVE

The goal of the study was to determine risk factors for maternal cardiac failure in pregnancy complicated with dilated cardiomyopathy (DCM).

STUDY DESIGN

The subjects were 29 patients diagnosed with DCM before conception or during the first 7 months of pregnancy. DCM was defined as left ventricle end-diastolic dimension (LVDd)≥48 mm and/or fractional shortening (%FS)≤30% on echocardiography. Patients were followed until at least 1 year after delivery and were categorized into a poor prognosis group (n=6; death or end stage heart failure of New York Heart Association (NYHA) class III and IV) and a good prognosis group (n=23; all other cases).

RESULT

DCM was initially diagnosed during pregnancy in 6/6 and 8/23 patients in the poor and good prognosis groups, respectively (P<0.005). The %FS of the first test during pregnancy was 17.5±6.2 and 27.4±9.3% in the respective groups (P<0.005). In eight abortion cases with %FS 15.2±3.1%, %FS, cardiac function and NYHA class were maintained until 20 months after abortion. There was no relationship between LVDd and maternal outcome.

CONCLUSION

Onset during pregnancy and decreased %FS are risk factors for a poor maternal outcome in patients with DCM. Abortion prevents further deterioration of cardiac function in patients with a very low %FS.

Pregnancy-associated aortic dilatation or dissection in Japanese women with Marfan syndrome

BACKGROUND

Aortic dilatation and dissection are severe complications of pregnancy that may cause maternal death. The purpose of the present study was to investigate risk factors for aortic dilatation or dissection in pregnant Japanese women with Marfan syndrome.

METHODS AND RESULTS

A total of 28 patients with Marfan syndrome were investigated retrospectively during pregnancy and after delivery at 1 institution. These patients were divided into 2 groups: those who experienced aortic dilatation or dissection (group D, n=11) and those who did not (group ND, n = 17). In group D, aortic dilatation or dissection occurred in 7 cases during pregnancy (2 in the 2(nd) trimester, 5 in the 3(rd) trimester) and 4 cases after birth. The 2 cases in the 2nd trimester involved aortic dilatation > 60mm and those patients underwent hemiarch replacement and a David operation, respectively. Delivery by cesarean section (64% vs. 18%, P < 0.05), sinus of Valsalva ≥ 40mm (86% vs. 21%, P < 0.05), aortic size index (size of sinus of Valsalva/body surface area) ≥ 25 mm/m² (7/7, 100% vs. 0/14, 0%, P < 0.0001), and faster growth of the sinus of the Valsalva (median, [interquartile range]: 0.41 mm/month [0.23-0.66 mm/month] vs. 0.05 mm/month [-0.13 to 0.22 mm/month]; P < 0.05) were significantly higher in group D than in group ND.

CONCLUSIONS

A large sinus of Valsalva, increased aortic size index, and rapid growth of the sinus of Valsalva are risk factors for aortic dilatation or dissection in pregnant Japanese women with Marfan syndrome.

Heterogeneity of regional systolic function detected by tissue Doppler imaging is linked to impaired global left ventricular relaxation in hypertrophic cardiomyopathy

OBJECTIVE

To evaluate regional and global left ventricular (LV) function and LV wall thickness (LVWT) in patients with hypertrophic cardiomyopathy (HCM).

DESIGN AND SETTING

Observational study at the National Cardiovascular Centre and Nagoya University Hospital in Japan.

PARTICIPANTS

Thirty-six patients with HCM and 16 patients with hypertensive LV hypertrophy (LVH).

MAIN OUTCOME MEASURES

Conventional echocardiography and strain rate (SR) imaging derived from tissue Doppler imaging were performed. Systolic strain (epsilon(sys)), peak systolic SR (SR(sys)), peak early diastolic SR (SR(dia)) and LVWT were obtained from eight LV segments. LV pressure was simultaneously recorded with a high-fidelity micromanometer.

RESULTS

The regional epsilon(sys) and SR(sys) were correlated with LVWT in patients with HCM (r = 0.50, p<0.001 and r = 0.63, p<0.001, respectively) but not in patients with hypertensive LVH. The standard deviations of LVWT, epsilon(sys) and SR(sys) obtained from the eight LV segments of each subject were greater for patients with HCM than for patients with hypertensive LVH. The standard deviation of LVWT was correlated with those of epsilon(sys) and SR(sys) (r = 0.55, p<0.001 and r = 0.56, p<0.001, respectively). The standard deviations of LVWT, epsilon(sys) and SR(sys) were correlated with tau (r = 0.35, p<0.05; r = 0.47, p<0.001; and r = 0.39, p<0.005, respectively).

CONCLUSIONS

Heterogeneity of regional LV systolic function detected by SR imaging is in part attributable to heterogeneity of LVH and may be linked to impaired global LV relaxation in HCM.

Cosmetic extended wear of oxygen permeable hard contact lenses: one year follow-up

The use of oxygen permeable hard contact lenses (Menicon EX) as a cosmetic extended wear lens was investigated in 44 patients (86 eyes). Extended wear of these lenses for a one year period was successfully accomplished by 31 patients (60 eyes). Visual acuity and wearing comfort were good, and severe complications such as corneal edema and ocular infection were not observed through the test period. In some patients with relatively high-grade astigmatism, the degree of corneal astigmatism showed a considerable reduction.