Clinical predictors of right ventricular dysfunction and association with adverse outcomes in peripartum cardiomyopathy

Abstract

Abstract Background Peripartum cardiomyopathy (PPCM) is a type of pregnancy associated heart failure with reduced ejection of unknown etiology that is associated with significant morbidity and mortality in young women. It is a leading cause of peripartum maternal death in the United States, with mortality as high as 25% in some cohorts, and accounts for approximately 50% of cases of maternal cardiogenic shock. Purpose We sought to identify factors associated with right ventricular (RV) dysfunction and elevated RV systolic pressure (RVSP) and association with adverse outcomes in PPCM. Methods We conducted a multi-center cohort study to identify subjects with PPCM with the following criteria: LVEF < 40%, development of heart failure within the last month of pregnancy or 5 months of delivery and no other identifiable cause of heart failure with reduced ejection fraction. Outcomes included a composite of 1) major adverse events (need for extra-corporeal membrane oxygenation, ventricular assist device, orthotopic heart transplantation or death) or 2) recurrent heart failure hospitalization. Results In all, 229 women (1993 to 2017) met criteria. Mean age was 32.4 ± 6.8 years, 28% were of African descent, 50 (22%) had RV dysfunction, and 38 (17%) had RVSP > = 30mmHg. After a median follow-up of 3.4 years (IQR 1.0-8.8), 58 (25%) experienced the composite outcome of adverse events. African descent, family history of cardiomyopathy, LVEF, and RVSP were significant predictors of RV dysfunction (Table 1). Using Cox proportional hazards models, we found that women with RV dysfunction were three times more likely to experience the adverse composite outcome: HR 3.21 (95% CI: 1.11-9.28), p = 0.03 in a multivariable model adjusting for age, race, body mass index, preeclampsia, hypertension, diabetes, kidney disease and LVEF. Women with RVSP >= 30mmHg had a lower probability of survival free from adverse events (log rank p = 0.04) (Figure 1). Conclusion African descent and family history of cardiomyopathy were significant predictors of RV dysfunction. RV dysfunction and elevated RVSP were significantly associated with a composite of major adverse cardiac events. This at-risk group may prompt closer monitoring, genetic testing, or early referral for advanced therapies.Table of predictorsSurvival curves