Persistent Left Ventricular Dysfunction Research Articles

The endocannabinoid-CB2 receptor axis protects the ischemic heart at the early stage of cardiomyopathy.

Ischemic heart disease is associated with inflammation, interstitial fibrosis and ventricular dysfunction prior to the development of heart failure. Endocannabinoids and the cannabinoid receptor CB2 have been claimed to be involved, but their potential role in cardioprotection is not well understood. We therefore explored the role of the cannabinoid receptor CB2 during the initial phase of ischemic cardiomyopathy development prior to the onset of ventricular dysfunction or infarction. Wild type and CB2-deficient mice underwent daily brief, repetitive ischemia and reperfusion (I/R) episodes leading to ischemic cardiomyopathy. The relevance of the endocannabinoid-CB2 receptor axis was underscored by the finding that CB2 was upregulated in ischemic wild type cardiomyocytes and that anandamide level was transiently increased during I/R. CB2-deficient mice showed an increased rate of apoptosis, irreversible loss of cardiomyocytes and persistent left ventricular dysfunction 60days after the injury, whereas wild type mice presented neither morphological nor functional defects. These defects were due to lack of cardiomyocyte protection mechanisms, as CB2-deficient hearts were in contrast to controls unable to induce switch in myosin heavy chain isoforms, antioxidative enzymes and chemokine CCL2 during repetitive I/R. In addition, a prolonged inflammatory response and adverse myocardial remodeling were found in CB2-deficient hearts because of postponed activation of the M2a macrophage subpopulation. Therefore, the endocannabinoid-CB2 receptor axis plays a key role in cardioprotection during the initial phase of ischemic cardiomyopathy development.

Peripartum Cardiomyopathy: Predictors of Recovery and Current State of Implantable Cardioverter-Defibrillator Use

The purpose of this study was to identify the predictors of left ventricular (LV) recovery in patients with peripartum cardiomyopathy (PPCM) and to record rates of implantable cardioverter-defibrillator (ICD) use. PPCM is a rare, life-threatening disease. The use of ICDs has not been clearly understood in this patient group. Identification of the predictors of persistent LV dysfunction can help select patients at risk for sudden cardiac death. A retrospective study was conducted at 2 academic centers between January 1, 1999, and December 31, 2012. Clinical and demographic variables and delivery records of patients with a diagnosis of PPCM (International Classification of Diseases, 9th Revision code 674.5) were reviewed. Improvement in LV function was noted from echocardiography reports. The total sample comprised 100 patients, of whom 55% were African Americans, 39% were Caucasians, and 6%were Hispanic, with a mean age of 30 ± 6 years. Mean left ventricular ejection fraction (LVEF) at diagnosis was 28 ± 9%. Forty-two percent of patients showed improvement in LVEF over a mean duration of 33 ± 21 months. Postpartum diagnosis (hazard ratio: 3.0; p= 0.01) and Caucasian/Hispanic race (hazard ratio: 2.2; p= 0.01) were predictors of improvement in LVEF. Only 7 of the 58 patients (12%) who did not have improvement in their LVEF had an ICD implanted. There were 11 deaths, with a trend toward higher mortality in those who did not display improved LV function (15% vs. 5%; p= 0.1). More than one-third of women with PPCM improve LV function with delayed recovery noted in the majority of these patients. Caucasians and those diagnosed in the postpartum period appear to be the most likely to recover. The rate of ICD implantation for primary prevention of sudden cardiac death in this patient group is low.

Abstract 18179: Prognostic Markers of Left Ventricular Dysfunction in Patients With Newly Recognized Cardiomyopathy and Atrial Fibrillation

INTRODUCTION: Tachycardia-induced cardiomyopathy (TIC) is confirmed with the improvement in ventricular function following restoration of sinus rhythm or control of ventricular rate. We sought to identify characteristics which could predict recovery of left ventricular dysfunction (LVD) in patients who present with newly recognized cardiomyopathy and atrial fibrillation (AF). METHODS: 114 consecutive patients presenting for cardioversion to our institution with newly recognized LVD defined as LVEF ≤ 45% and AF were identified. Patients with known cardiomyopathy, without admission ECG or follow up echocardiogram were excluded. QRS duration from admission ECG was used as a binary variable (≥ 125 ms or < 125 ms) while LVEDD from admission echocardiogram was used as a binary variable (≥ 5.6 cm or < 5.6 cm). The outcome was a binary variable, resolution of cardiomyopathy (LVEF ≥ 45%) or persistence of cardiomyopathy (LVEF ≤ 45%). The outcome was analyzed with logistic regression model using STATA. The outcomes were adjusted for age, gender, obstructive sleep apnea, coronary artery disease, diabetes mellitus, hypertension, excessive alcohol ingestion, tobacco, beta blockers, ACE inhibitors and aldosterone antagonist. RESULTS: 92 patients met the inclusion and exclusion criteria. Possible TIC was diagnosed in 65 patients who had recovery of LVD. Mean QRS duration in patients with possible TIC was 101 +/- 18 ms while LVEDD was 5.21 +/- 0.67 cm. In patients with persistent LVD, mean QRS duration was 120 +/- 27 ms while LVEDD was 5.61 +/- 1.0 cm. Normal QRS duration (< 125 ms) on admission ECG was associated with a significantly higher incidence of LV functional recovery (adjusted odds ratio: 4.02; 95% CI: 1.21 - 13.33, p = 0.023). Normal LVEDD (<5.6 cm) on presentation was also associated with a significantly higher incidence of LV function recovery (adjusted odds ratio: 3.75; 95% CI: 1.43 - 9.85, p = 0.007). Next Step/Future: Normal QRS duration on admission ECG and LVEDD on admission echocardiogram in patients presenting with newly diagnosed AF and cardiomyopathy serve as good markers of LV function recovery. If confirmed by larger prospective series, QRS duration and LVEDD on presentation can be used as prognostic markers in patients with new onset AF and cardiomyopathy.

Electrophysiological Mapping and Radiofrequency Catheter Ablation for Ventricular Tachycardia in a Patient with Peripartum Cardiomyopathy

A 38-year-old female with prior failed endocardial ablation for ventricular tachycardia (VT) was referred for further treatment. She had been diagnosed with peripartum cardiomyopathy 7 years before and had persistent left ventricular dysfunction with an ejection fraction of 20%. Epicardial voltage mapping showed extensive epicardial scar despite absence of endocardial scar. Five distinct VT morphologies were induced. Ablation was aided by electrogram characteristics, pace mapping, entrainment mapping, and establishing electrical inexcitability along areas of epicardial scar. After epicardial ablation no sustained VT was induced. She had been doing well without VT occurrence but died 1 year later unexpectedly at home.

Early and late left ventricular effects of breast cancer chemotherapy: a prospective multi-centre study using advanced cardiac imaging

Background Myocardial dysfunction is a recognized toxicity of anthracycline (A) and herceptin (H) chemotherapy. Whilst there is much current focus on the incidence and magnitude of myocardial dysfunction following the A/H regimen, whether these changes are mediated by reversible or irreversible myocardial injury remains unknown. We sought to determine rates of persistent LV dysfunction at 12 months (as defined by left ventricular ejection fraction (LVEF) decrease by 10% or below lower limits of normal) following A/H and explore the mechanism of myocardial dysfunction using advance cardiac imaging.

Natural history, management, and outcomes of peripartum cardiomyopathy: an Irish single-center cohort study

Aim: To describe the natural history, management and outcomes of peripartum cardiomyopathy (PPCM) in an unselected Northern European population. Methods: A retrospective single-center observational study was performed at a tertiary referral heart failure and transplantation unit. Outcomes measured were baseline demographics, clinical presentation, course, and treatment. Echocardiographic findings were compared at baseline, 2 months, and 6 months. Results: Twelve cases of PPCM were identified between 2002 and 2008. Mean age was 34.7 years. Nine patients were multiparous and nine had preeclampsia. Ten patients presented in the first week postpartum. Two patients required inotropic support. Mean ejection fraction (EF) at presentation was 27% (SD = 8%) which improved to 47% (SD = 13%) at 6 months. At this time, 10 patients were asymptomatic and 6 had recovered normal cardiac function. Left ventricular (LV) function improved but did not reach normal limits in five cases. One case with persistent severe LV dysfunction required cardiac transplantation. One patient suffered an arrhythmic death several years after the 6 months follow-up period. Conclusions: PPCM is a rare condition. With appropriate therapy, a good clinical outcome is common but not universal. Continued deterioration requiring ventricular support and cardiac transplantation can occur. In our cohort, older maternal age, multiparity, and preeclampsia appeared to be risk factors.

Delayed recovery in peripartum cardiomyopathy: an indication for long‐term follow‐up and sustained therapy

Persistence of left ventricular (LV) systolic dysfunction after 6 months of diagnosis is believed to be a marker of an irreversible cardiomyopathy in peripartum cardiomyopathy (PPCM). We sought to determine the length of time required for recovery of LV systolic function (LVSF) in patients with PPCM. Forty-two consecutive women with PPCM were enrolled in this prospective study. The minimum required time of follow-up for inclusion was 30 months. Each patient underwent transthoracic echocardiography, and plasma brain natriuretic peptide (BNP) and C-reactive protein measurement at admission, and every 3 months. Early recovery was defined as normalization of LVSF at 6 months post-diagnosis. Delayed recovery was defined if the length of time required for recovery of LVSF was longer than 6 months. Persistent left ventricular dysfunction (PLVD) was defined as an ejection fraction of <50% at the end of follow-up. Twenty patients (47.6%) recovered completely, 10 died (23.8%), and 12 (28.6%) had PLVD. Average time to complete recovery was 19.3 months after initial diagnosis (3-42 months). Early recovery was observed only in six patients (30%), whereas delayed recovery was observed in 14 out of 20 patients (70%). Patients with complete recovery were more likely to have a higher LV ejection fraction and smaller LV end-systolic dimensions at baseline. Full recovery of LVSF in PPCM patients often requires longer than 6 months.

The 12-lead ECG in peripartum cardiomyopathy

The value of the 12-lead electrocardiogram (ECG) to provide prognostic information in the deadly and disabling syndrome peripartum cardiomyopathy (PPCM) is unknown. To determine the prevalence of major and minor ECG abnormalities in PPCM patients at the time of diagnosis, and to establish whether there are ECG correlates of persistent left ventricular dysfunction and/or clinical stability at six months of follow up, where available. Twelve-lead ECGs were performed at the point of diagnosis on 78 consecutive women presenting with PPCM to two tertiary centres in South Africa and 44 cases (56%) at the six-month follow up. Blinded Minnesota coding identified major ECG abnormalities and minor ECG changes. The cohort mainly comprised young women of black African ancestry (90%) [mean age 29 ± 7 years and median body mass index 24.3 (IQR: 22.7-27.5) kg/m(2)]. The majority of cases (n = 70; 90%) presented in sinus rhythm (mean heart rate 100 ± 21 beats/min). At baseline, at least one ECG Abnormality/variant was detected in 96% of cases. Major ECG abnormalities and minor changes were detected in 49% (95% CI: 37-60%) and 62% (95% CI: 51-74%) of cases, respectively; the most common being T-wave changes (59%), p-wave abnormality (29%) and QRS-axis deviation (25%). Of the 44 cases (56%) reviewed at six months, normalisation of the 12-lead ECG occurred in 25%; the most labile ECG features being heart rate (mean reduction of 27 beats/min; p < 0.001) and abnormal QRS axis (36 vs 14%; p = 0.014). On an adjusted basis, major T-wave abnormalities on the baseline 12-lead ECG were associated with lower left ventricular ejection fraction (LVEF) at baseline (average of -9%, 95% CI: -1 to -16; p = 0.03) and at six months (-12%; 95% CI: -4 to -24; p = 0.006). Similarly, baseline ST-segment elevation was also associated with lower LVEF at six months (-25%; 95% CI: -0.7 to -50; p = 0.04). In this unique study, we found that almost all women suffering from PPCM had an 'abnormal' 12-lead ECG. Pending more definitive studies, the ECG appears to be a useful adjunctive tool in both screening and prognostication in resource-poor settings.

Novel Postoperative Use of Beta-Blocking Medication for Infants With Left Ventricular Outflow Obstruction and Diastolic Myocardial Dysfunction

Severe left ventricular outflow obstruction often is associated with diastolic left ventricular myocardial dysfunction and tachycardia despite successful initial treatment. The authors have used esmolol to lower heart rate in this setting for successful weaning of patients from ventilation in postoperative recovery. Their limited experience supports the beneficial effect of continuous esmolol administration on infants with persistent tachycardia and severe left ventricular diastolic dysfunction in postoperative cardiac intensive care.

Subcellular Structures and Function of Myocytes Impaired During Heart Failure Are Restored by Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT) is an established treatment for patients with chronic heart failure. However, CRT-associated structural and functional remodeling at cellular and subcellular levels is only partly understood. To investigate the effects of CRT on subcellular structures and protein distributions associated with excitation-contraction coupling of ventricular cardiomyocytes. Our studies revealed remodeling of the transverse tubular system (t-system) and the spatial association of ryanodine receptor (RyR) clusters in a canine model of dyssynchronous heart failure (DHF). We did not find this remodeling in a synchronous heart failure model based on atrial tachypacing. Remodeling in DHF ranged from minor alterations in anterior left ventricular myocytes to nearly complete loss of the t-system and dissociation of RyRs from sarcolemmal structures in lateral cells. After CRT, we found a remarkable and almost complete reverse remodeling of these structures despite persistent left ventricular dysfunction. Studies of whole-cell Ca(2+) transients showed that the structural remodeling and restoration were accompanied with remodeling and restoration of Ca(2+) signaling. DHF is associated with regional remodeling of the t-system. Myocytes undergo substantial structural and functional restoration after only 3 weeks of CRT. The finding suggests that t-system status can provide an early marker of the success of this therapy. The results could also guide us to an understanding of the loss and remodeling of proteins associated with the t-system. The steep relationship between free Ca(2+) and contraction suggests that some restoration of Ca(2+) release units will have a disproportionately large effect on contractility.

Abstract 17528: Delayed Rocovery in Peripartum Cardiomyopathy: An Indication for Long-Term Follow-Up and Sustained Therapy

Background: Persistence of left ventricle systolic dysfunction after 6 months of diagnosis is believed to be a marker of an irreversible cardiomyopathy and worse survival in peripartum cardiomyopathy (PPCM). We sought to determine the length of time required for recovery of left ventricle systolic function (LVSF) in patients with PPCM. Methods: Forty-two consecutive women with PPCM treated at two tertiary hospitals in Turkey were enrolled in this prospective study over a 5-year period. The minimum required time of follow-up for inclusion was 30 months (range 30-65 months). Clinical evaluation, B-type natriuretic peptide (BNP) and C-reactive protein (CRP) concentrations, and transthoracic echocardiography were evaluated at baseline, every 3 months during the first year, and every 6 months thereafter. Rapid recovery is defined as resolution of heart failure symptoms or signs and normalization of LVSF at 6 months post-diagnosis. Delayed recovery is defined if the length of time required for recovery of LVSF was longer than 6 months. Persistent left ventricular dysfunction (PLVD) is defined as an ejection fraction of less than 50 % at the end of follow-up. Results: Twenty patients (47.6%) recovered completely, 10 died (23.8%), and 12 (28.6%) were left with PLVD. Average time to complete recovery was 19.3 months after initial diagnosis (3-42 months). Rapid recovery is observed only in 6 patients (30%) whereas delayed recovery is observed in 14 out of 20 patients (%70) (Figure). Persistent elevation of plasma BNP and CRP above the cut-off values at 3th month is predictive of delayed recovery. Conclusions: Full recovery of LVSF in PPCM patients often requires longer than 6 months. Persistent elevation of plasma CRP and BNP above the cut-off values portends a slower response.

650 Insulin treatment normalizes noradrenaline levels and cardiac sympathetic innervation in diabetic rats

650 Insulin treatment normalizes noradrenaline levels and cardiac sympathetic innervation in diabetic rats

Prediction of life-threatening arrhythmias: Multifactorial risk stratification following acute myocardial infarction

During the last three decades great efforts have been made to stratify patients following myocardial infarction based on the assessment of residual ischemia, persistent left ventricular dysfunction, and recurrent ventricular arrhythmias. Autonomic function assessment has recently provided a new perspective in postinfarction risk stratification. However, the predictive accuracy of the commonly used invasive and noninvasive methods is low. A combination of these techniques improves their power of risk stratification. Other variables for risk stratification, such as the QT interval, remain to be fully evaluated. Modification of the value of previously established techniques should be expected in the interventional and thrombolytic era. Further study should be aimed at improving our understanding of the underlying risk mechanisms following acute myocardial infarction. This understanding is of fundamental importance since the purpose of postinfarction risk stratification is to decrease the subsequent mortality rate.

One-Year Safety Analysis of the COMPARE-AMI Trial: Comparison of Intracoronary Injection of CD133+ Bone Marrow Stem Cells to Placebo in Patients after Acute Myocardial Infarction and Left Ventricular Dysfunction

Bone marrow stem cell therapy has emerged as a promising approach to improve healing of the infarcted myocardium. Despite initial excitement, recent clinical trials using non-homogenous stem cells preparations showed variable and mixed results. Selected CD133+ hematopoietic stem cells are candidate cells with high potential. Herein, we report the one-year safety analysis on the initial 20 patients enrolled in the COMPARE-AMI trial, the first double-blind randomized controlled trial comparing the safety, efficacy, and functional effect of intracoronary injection of selected CD133+ cells to placebo following acute myocardial infarction with persistent left ventricular dysfunction. At one year, there is no protocol-related complication to report such as death, myocardial infarction, stroke, or sustained ventricular arrhythmia. In addition, the left ventricular ejection fraction significantly improved at four months as compared to baseline and remained significantly higher at one year. These data indicate that in the setting of the COMPARE-AMI trial, the intracoronary injection of selected CD133+ stem cells is secure and feasible in patients with left ventricle dysfunction following acute myocardial infarction.

Effect of levosimendan and predictors of recovery in patients with peripartum cardiomyopathy, a randomized clinical trial

Levosimendan is a promising new inodilator agent but its effectiveness in peripartum cardiomyopathy (PPCM) has not been tested in a clinical trial. The authors sought to evaluate the effect of levosimendan therapy and to determine the predictors of clinical outcome in patients with PPCM. The authors prospectively randomized 24 consecutive women with PPCM. Twelve patients (control group) were randomized to conventional heart failure therapy and 12 patients (levosimendan group) were randomized to levosimendan in addition to the conventional therapy. Mean follow-up period was 20.9±9months (ranged 12-38months). The two groups did not differ in baseline demographic and echocardiographic characteristics. Eleven patients (45.8%) recovered completely (6 in control group and 5 in levosimendan group, p>0.05), 6 died (25%) (3 in control group and 3 in levosimendan group), and 7 (29.1%) were left with persistent left ventricular dysfunction (PLVD) (3 in control group and 4 in levosimendan group, p>0.05). There were significant differences in baseline characteristics between deceased patients and survivors including left ventricular end-diastolic diameter (7.1±0.6 vs. 6.4±0.5cm, p=0.031), left ventricular end-systolic diameter (LVESD) (6.4±0.8 vs. 5.5±0.6cm, p=0.027), left ventricular ejection fraction (LVEF) (19.7 vs. 27.4%, p=0.025), and left atrial diameter (4.9±0.3 vs. 4.3±0.4cm, p=0.011). Addition of levosimendan to conventional therapy did not improve outcome in patients with PPCM. In patients with PLVD or patients who died, LVEF, LVESD and left atrial diameter were worse than those with complete resolution.

IMPACT-CABG Trial: Implantation of CD133+Stem Cells in Patients Undergoing Coronary Bypass Surgery—Presentation of the First Treated Patient

The IMPACT-CABG study is the first Canadian randomized-controlled phase II clinical trial aiming to assess the effect of intramyocardial (IM) injections of CD133+-selected stem cells in patients referred for coronary artery bypass graft (CABG) with a “chronic” myocardial infarction and persistent left ventricular dysfunction. Patients are followed for 2 years with different imaging techniques including the stress magnetic resonance to evaluate the global and regional myocardial viability. Before the beginning of the randomization, the 5 first patients are treated in an open-label fashion to assess safety and feasibility of the IM CD133+ injections. Herein, we report the first Canadian patient treated with IM injection of CD133+ cells during CABG surgery as part of the IMPACT-CABG trial.

Vasoreactivity Testing with Inhaled Iloprost and Nitric Oxide in Pulmonary Arterial Hypertension

Commonest ECG at admission was normal in 14 (34%); ST elevation in 10 (24%). QTc was prolonged in 36% of patients at admission and it was noted to be prolonged in 72% of patients at 48 hours after admission. At three months,QTc had normalised in 90%. Three had newonset AF reverting to sinus rhythm, without recurrence. One patient was cardioverted from VF. Echo confirmed apical ballooning in 97%.All except one patient recovered. Conclusion: Takotsubo cardiomyopathy is an acute, mostly reversible LV dysfunction. The prognosis is good with complete recovery within few weeks. In our study there was one death and one person had persistent LV dysfunction. doi:10.1016/j.hlc.2011.05.192

Takotsubo Cardiomyopathy: A Case of Persistent Apical Ballooning Complicated by an Apical Mural Thrombus

Takotsubo cardiomyopathy (TTC) is an infrequent cardiac syndrome characterized by acute onset chest pain with apical ballooning on echocardiography. It is often triggered by severe emotional or physical stress, and in contrast to acute myocardial infarction (AMI), the regional wall motion abnormality returns to normal within days. Here, we describe a 62-year-old female who presented with acute onset chest pain during treatment for a liver abscess. We presumed a diagnosis of AMI because of ST segment elevation on electrocardiography and elevated cardiac enzyme levels. However, the patient's coronary arteries were normal on angiography, and apical ballooning was seen on echocardiography. A diagnosis of TTC was made, and the patient was managed with intensive cardiopulmonary support using vasopressors in our hospital's medical intensive care unit. The patient's symptoms improved, but persistent severe left ventricular dysfunction was detected on follow-up echocardiography. After 5 weeks, a new apical mural thrombus appeared, and anticoagulation therapy was started. The apical ballooning persisted 3 months later, although the patient's overall ejection fraction was slightly improved. The apical thrombus was completely resolved without any embolic event. Non-adrenergic inotropics can be recommended in TTC with shock, and clinicians should keep in mind the potential risk of thrombus formation and cardioembolism.

Implantation of a CRT-D in a Patient with Dextrocardia and Situs Inversus Totalis, Who Has Persistent Left Ventricular Dysfunction with VT/VF

Introduction: Dextrocardia is rare, with an incidence of 0.4 per 10,000 live birth. One-third of the cases are associated with situs inversus, where the major visceral organs, including the heart, are mirror image of their normal positions. Case Presentation. The patient was a 62-year-old woman with known dextrocardia and situs inversus totalis, who was diagnosed as hypertrophic cardiomyopathy in the 1990s. May 10, 2010, she visited our hospital with dyspnea and wheeze. After a while, she was founded to be in ventricular fibrillation, and she was successfully converted to sinus rhythm by multiple external defibrillations. Her transthoracic echocardiography was significant for persistent left ventricular dysfunction with an estimated ejection fraction of 28% and 12-lead electrocardiogram showed sinus bradycardia with left bundle branch block, QRS duration of 160 msec and QTc interval of 0.6. A cardiac catheterization revealed no significant coronary artery disease, non-ischemic cardiomyopathy. We concluded that it was necessary for the patient to receive implantation of a bi-ventricular implantable cardioverter defibrillator (CRT-D), and successfully performed on June 7, 2010. We report a rare case of a CRT-D implantation in a patient with dextrocardia and situs inversus totalis.

Pregnancy and subsequent pregnancy outcomes in peripartum cardiomyopathy

To study the clinical profile and management of peripartum cardiomyopathy, and to analyze the pregnancy outcomes of pregnant women with this disorder as well as its effect on subsequent pregnancies. All patients admitted with peripartum cardiomyopathy from July 2006 to June 2009 by the Departments of Cardiology and Obstetrics and Gynecology from the Institute of Post Graduate Medical Education and Research, Kolkata, India, were considered for this observational study. Thirty-six women with 42 pregnancies (36 first pregnancies and six second pregnancies in the same patients) were evaluated. Primiparas constituted 39% (14/36) of the total study population. Twenty-six women (72%) were clinically improved and in 17 (48%) the left ventricular functional status returned to normal. Five cases (14%) developed persistent cardiomyopathy (persistent left ventricular dysfunction beyond six months of presentation), and five women (14%) presented with thromboembolic events and anticoagulation was used as secondary prophylaxis. Maternal mortality was 14% (5/36). Among all live babies two had intrauterine growth restriction (IUGR) and another two died during the neonatal period. Of the six women with subsequent pregnancies, the patient with persistent cardiomyopathy died after delivering a stillborn baby. The remaining five cases with normal left ventricular functional status had favorable fetal outcomes; however, the mothers experienced morbidities such as symptoms of heart failure (two cases) and one of them progressed to persistent cardiomyopathy. Subsequent pregnancies should be discouraged as it increases the risk of recurrence of left ventricular dysfunction. Anticoagulation may be considered as a primary prevention of thromboembolism in pregnant mothers with peripartum cardiomyopathy.