Peripartum Cardiomyopathy Presenting Research Articles

The "arrhythmic" presentation of peripartum cardiomyopathy: case series and critical review of the literature.

Peripartum Cardiomyopathy (PPCM) is a polymorphic myocardial disease occurring late during pregnancy or early after delivery. While reduced systolic function and heart failure (HF) symptoms have been widely described, there is still a lack of reports about the arrhythmic manifestations of the disease. Most importantly, a broad range of unidentified pre-existing conditions, which may be missed by general practitioners and gynecologists, must be considered in differential diagnosis. The issue is relevant since some arrhythmias are associated to sudden cardiac death occurring in young patients, and the overall risk does not cease during the early postpartum period. This is why multimodality diagnostic workup and multidisciplinary management are highly suggested for these patients. We reported a series of 16 patients diagnosed with PPCM following arrhythmic clinical presentation. Both inpatients and outpatients were identified retrospectively. We performed several tests to identify the arrhythmic phenomena, inflammation and fibrosis presence. Cardiomyopathies phenotypes were reclassified in compliance with the updated ESC guidelines recommendations. Arrhythmias were documented in all the patients during the first cardiological assessment. PVC were the most common recorder arrhythmias, followed by VF, NSVT, AF, CSD.

Clinical presentation and outcomes of peripartum cardiomyopathy in the Middle East: a cohort from seven Arab countries.

AimsPublished data on the clinical presentation of peripartum cardiomyopathy (PPCM) are very limited particularly from the Middle East. The aim of this study was to examine the clinical presentation, management, and outcomes of patients with PPCM using data from a large multicentre heart failure (HF) registry from the Middle East.Methods and resultsFrom February to November 2012, a total of 5005 consecutive patients with HF were enrolled from 47 hospitals in 7 Middle East countries. From this cohort, patients with PPCM were identified and included in this study. Clinical features, in‐hospital, and 12 months outcomes were examined. During the study period, 64 patients with PPCM were enrolled with a mean age of 32.5 ± 5.8 years. Family history was identified in 11 patients (17.2%) and hypertension in 7 patients (10.9%). The predominant presenting symptom was dyspnoea New York Heart Association class IV in 51.6%, class III in 31.3%, and class II in 17.2%. Basal lung crepitations and peripheral oedema were the predominant signs on clinical examination (98.2% and 84.4%, respectively). Most patients received evidence‐based HF therapies. Inotropic support and mechanical ventilation were required in 16% and 5% of patients, respectively. There was one in‐hospital death (1.6%), and after 1 year of follow‐up, nine patients were rehospitalized with HF (15%), and one patient died (1.6%).ConclusionsA high index of suspicion of PPCM is required to make the diagnosis especially in the presence of family history of HF or cardiomyopathy. Further studies are warranted on the genetic basis of PPCM.

Clinical Presentation and Outcomes of Peri-Partum Cardiomyopathy in the Middle-East: A Report from Seven Arab Countries

Background: Published data on the clinical presentation of peripartum cardiomyopathy (PPCM) are very limited particularly from the Middle East. The aim of this study was to examine the clinical presentation, management and outcomes of patients with PPCM using data from a large multicentre heart failure (HF) registry from the Middle-East. Methods: From February to November, 2012, a total of 5005 consecutive patients with HF were enrolled from 47 hospitals in 7 Middle East countries. From this cohort, patients with PPCM were identified and included in this study. Clinical features, in-hospital and 12 months outcomes were examined. Findings: During the study period 64 patients with PPCM were enrolled with a mean age of 32.5 ±5.8 years. Family history was identified in 11 patients (17.2%) and hypertension in 7 patients (10.9%). The predominant presenting symptom was dyspnea with NYHA class VI in 51.6%, class III in 31.3% and class II in 17.2%. Basal lung crepitations and peripheral edema were the predominant signs on clinical examination (98.2% and 84.4%, respectively). Most patients received evidence-based HF therapies. Inotropic support and mechanical ventilation were required in 16% and 5% of patients, respectively. There was one in-hospital death (1.6%), and over one-year of follow-up 9 patients were re-hospitalized with HF (15%) and one patient died (1.6%). Interpretation: A high index of suspicion of PPCM is required to make the diagnosis especially in the presence of family history of HF or cardiomyopathy. Further studies are warranted on the genetic basis of PPCM. Trial Registration: The study was registered at clinicaltrials.gov with the number NCT01467973. Funding Statement: Gulf CARE was an investigator-initiated study conducted under the auspices of the Gulf Heart Association and funded by Servier, Paris, France; and (for centres in Saudi Arabia) by the Saudi Heart Association [The Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (Research group number: RG -1436-013)]. The publication of this article was funded by the Qatar National Library. Declaration of Interests: The authors report no relationships that could be construed as a conflict of interest. Ethics Approval Statement: Study ethical approval was obtained from all concerned authorities in the recruiting centers. Informed consent was obtained from all patients.

Peripartum cardiomyopathy presenting as renal infarct - A rare case report

Peripartum cardiomyopathy presenting as renal infarct - A rare case report

A Population-based Study of Peripartum Cardiomyopathy in Southern Israel: Are Bedouin Women a New High-risk Group?

ObjectivesPeripartum cardiomyopathy (PPCM) is a serious complication of pregnancy. Studies investigating the risk factors that worsen outcomes have yielded conflicting results. The goals of this study were to describe the clinical and echocardiographic characteristics of PPCM in a single tertiary center and to determine the prognostic factors associated with persistence of left ventricular (LV) dysfunction in these women.Study DesignThis retrospective cross-sectional population-based cohort study included all patients with PPCM confirmed by echocardiography who delivered at our center from 2004 to 2014. Two groups were compared to determine long-term maternal outcome: (1) those who recovered normal LV function; and (2) those with residual systolic LV dysfunction.ResultsThere were 148,994 deliveries during the study period. Of these, 89,196 patients were Bedouin and 59,798 were non-Bedouin. Forty-six patients met the PPCM study inclusion criteria. The PPCM prevalence for the total deliveries was 1:3,239. The PPCM prevalence among Bedouin patients was 1:2,787 versus non-Bedouin patients of 1:4,983 (P=0.037). None of the women had pre-existing chronic hypertension, and there was no maternal death. Patients who had severe or moderate LV dysfunction at the clinical presentation of PPCM were less likely to regain normal LV function than those with mild dysfunction (81.2% versus 56.7%, P=0.009). Based on initial echocardiogram, a trend toward residual LV dysfunction was noted in patients with a dilated left ventricle as compared to those with a non-dilated left ventricle (18.8% versus 6.7%, P=0.32). A hypokinetic right ventricle was found in 15.2% of the women who suffered from PPCM.ConclusionIn our cohort, Bedouin women may be at increased risk for PPCM, and patients with severe LV dysfunction have a lower chance of recovery from PPCM.

A Case Presentation of Peripartum Cardiomyopathy with Multiple Complications and Associated Treatment Dilemmas

A Case Presentation of Peripartum Cardiomyopathy with Multiple Complications and Associated Treatment Dilemmas

141 Eclampsia as the first presentation of peripartum cardiomyopathy

Introduction In some cases eclampsia (which is the main cause of mortality during pregnancy) may be associated with peripartum cardiomyopathy (the main cause of serious complications during pregnancy and postpartum period). Case report Female patient 36 years old, in the 30th week of gestational (the first pregnancy), previously completely healthy, was admitted to hospital due to syncope, convulsion and hypertension (160/100 mmHg). The caesarean delivery was performed immidiately. ECG and echocardiography were without pathological findings, but because of elevated troponin I (0,19) and NT pro BNP (1500), CT coronary angiography was performed. The finding on coronary arteries was completely normal. After improvement in clinical symptoms, values of blood pressure and laboratory findings, patient was discharged. Three months later (in the meantime she didn’t come on the routine clinical folow-up) she was again admitted to hospital due to dyspnoea, peripheral edema and palpitations. Symptoms had begun ten days before that. Physical examination indicated systolic murmur at the apex, signs of left and right heart failure. Laboratory analysis showed leukocytosis, anemia, increased liver ensymes AST (62), LDH (531), uric acid (548), CRP (7,5) and significant increase of NT pro BNP (20975). Electrocardiogram pointed to tachycardia and T-wave inversion in standard and precordial leads. Chest X-ray demonstrated enlarged heart shadow without pathological changes in the lungs. The patient underwent an echocardiography exam which showed dilated left ventricle, global hypokinetic, with low ejection fraction (25%) and with large thrombus in the apex, with very high embolic potential. It also demonstrated moderate mitral regurgitation. The patient was treated according to guidelines on acute and chronic heart failure with ACE inhibitors, beta blockers, diuretics, mineralocorticoid receptor antagonists, also with anticoagulant therapy and supstitution therapy of folic acid and iron, with addition of bromocriptine. Two months later she was symptomless, while echocardiography showed improvement in ejection fraction (45–50%), reduction of mitral regurgitation and completely resolution of the left ventricle thrombus. Finally, about twelve months later, coming to a complete clinical, laboratory, ECG and echocardiography restitution. Conclusion In case of presentation of eclampsia it is necessary to follow up the patient frequently not to miss the beginning of sytolic disfunction due to peripartum cardiomyopathy, which may be coused by eclampsia. It is also important to be aware that some cases need more time (not only six months) for complete restitution.

Peripartum Cardiomyopathy (PPCM): Dual Case Report and Review of Literatures

Introduction:Peripartum cardiomyopathy (PPCM), unexplained heart failure is a rare complication of pregnancy that occurs at the end of pregnancy or early during the postpartum period. PPCM is a diagnosis of exclusion that is made after other possible etiologies have been eliminated. The presentation of PPCM is generally during the early postpartum period where the patient will typically present with heart failure symptoms; these symptoms are often mistaken for being part of the normal puerperal experience. Although there are many risk factors for the development of PPCM, the greatest risk factors include being of African descent, having multiple gestation pregnancies and advanced maternal age. The etiology of PPCM has never been completely understood. However, it has been postulated that it is related to persistent viral antigen exposure. The management guidelines of the patient with PPCM generally follow guidelines for the management of congestive heart failure resulting from other etiologies, with the exception that angiotensin-converting-enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs), contraindicated during pregnancy, because of their teratogenic effects. Case description:We present two cases of peripartum cardiomyopathy (PPCM) with the discussion of management and literature review. Conclusion:Although the prognosis of PPCM is usually favorable, maternal mortality has been reported. Therefore, clinicians must remain vigilant to facilitate timely recognition of the peripartum complication. Serious nonfatal complications including cardiacdysrhythmias, progressive heart failure requiring heart transplantation, and thromboembolic events manifesting as cerebral vascular accidents and peripheral arterial embolism may occur. Early diagnosis and prompt treatment is associated with a decrease in morbidity and mortality associated with PPCM.

Low systolic blood pressure and high resting heart rate as predictors of outcome in patients with peripartum cardiomyopathy

BackgroundPatients with peripartum cardiomyopathy (PPCM) present with low blood pressure (SBP) often preventing uptitration of heart failure medication. We aimed to study prediction of risk and the contribution of high resting heart rate (HR) and low SBP to risk in recent onset of PPCM. MethodsClinical assessment with HR and SBP, echocardiography and laboratory results were obtained at baseline and at six months on 206 patients with recent onset PPCM enrolled at two tertiary care centers in South Africa. Poor outcome was defined as the combined endpoint of death, LVEF<35% or remaining in New York Heart Association (NYHA) functional class III/IV at six months. Complete LV recovery was defined as LVEF≥55% at six months. ResultsPoor outcome was observed in 110 of 220 patients (53%), with 26 patients dying at six months (12.6%). There were 98 (47.5%) patients with SBP≤110mmHg. Patients with high HR (HR≥100) and low SBP (<110mmHg) tended to have worse outcomes than patients below the HR median and high SBP. PPCM patients with low SBP and high HR were less likely to be on ACE-inhibitors (n=35, 69% versus n=129, 84%, p=0.024) and on the beta blocker carvedilol (n=24, 47% versus n=98, 64%, p=0.047). Low SBP, high HR and left ventricular end diastolic diameter at baseline were predictors of poor outcome. Patients with low SBP and high HR had the highest mortality (p=0.0023). ConclusionsThese findings suggest increased risk in patients with PPCM presenting with low SBP and high HR on standard heart failure medication possibly having implications on HF management.

English

Peripartum cardiomyopathy (PPCM) is a rare but sometimes life-threatening form of dilated cardiomyopathy. The exact cause is unclear. It is associated with excess morbidity and mortality in women of childbearing age. Incidence of PPCM ranges from 1 in 2000 to 4000 pregnancies. The diagnostic criteria are onset of heart failure in the last month of pregnancy or in first 5 months postpartum, absence of determinable cause for cardiac failure, and absence of a demonstrable heart disease before the last month of pregnancy. There must be echocardiographic features of left ventricular dysfunction. The known risk factors include multiparity, twin births, advanced maternal age, preeclampsia, gestational hypertension, and black race. The usual clinical presentation of patients with peripartum cardiomyopathy is similar to that of patients with systolic congestive heart failure. Treatment is limited to use of drugs for symptomatic control, although recent studies indicate the usefulness of new drugs. About half the patients of peripartum cardiomyopathy recover without any complications. The prognosis is poor in patients with persistent cardiomyopathy. Persistence of disease after 6 months indicates irreversible cardiomyopathy and portends worse survival. Recurrence in subsequent pregnancies remains high. In this case report, we describe the unusual presentation of PPCM in a young woman with term pregnancy.

Peripartum Cardiomyopathy Presenting with Predominant Left Ventricular Diastolic Dysfunction: Efficacy of Bromocriptine

Management of patients with peripartum cardiomyopathy (PPCM) is still a major clinical problem, as only half of them or slightly more show complete recovery of left ventricular (LV) function despite conventional evidence-based treatment for heart failure. Recent observations suggested that bromocriptine might favor recovery of LV systolic function in patients with PPCM. However, no evidence exists regarding its effect on LV diastolic dysfunction, which is commonly observed in these patients. Tissue Doppler (TD) is an echocardiographic technique that provides unique information on LV diastolic performance. We report the case of a 37-year-old white woman with heart failure (NYHA class II), moderate LV systolic dysfunction (ejection fraction 35%), and severe LV diastolic dysfunction secondary to PPCM, who showed no improvement after 2 weeks of treatment with ramipril, bisoprolol, and furosemide. At 6-week followup after addition of bromocriptine, despite persistence of LV systolic dysfunction, normalization of LV diastolic function was shown by TD, together with improvement in functional status (NYHA I). At 18-month followup, the improvement in LV diastolic function was maintained, and normalization of systolic function was observed. This paper might support the clinical utility of bromocriptine in patients with PPCM by suggesting a potential benefit on LV diastolic dysfunction.

Peripartum Cardiomyopathy Presenting with Syncope due to Torsades de Pointes: a Case of Long QT Syndrome with a Novel KCNH2 Mutation

Peripartum cardiomyopathy (PPCM) is a cardiomyopathy of unknown cause that occurs in the peripartum period. We report a case of PPCM presenting with syncope 1 month after an uncomplicated delivery. Electrocardiography showed Torsades de pointes (TdP) and QT interval prolongation. Echocardiography showed left ventricular systolic dysfunction and endomyocardial biopsy showed myocyte degeneration and fibrosis. Administration of magnesium sulfate and temporary pacing eliminated recurrent TdP. Genetic analyses revealed that recurrent TdP occurred via electrolyte disturbance and cardiac failure due to PPCM on the basis of a novel mutation in KCNH2, a gene responsible for inherited type 2 long QT syndrome.

Peripartum cardiomyopathy presenting as splenic infarct

Peripartum cardiomyopathy presenting as splenic infarct

Peripartum Cardiomyopathy Presenting as Diastolic Heart Failure

The authors describe a case of peripartum cardiomyopathy due to diastolic dysfunction. The patient presented postpartum with signs and symptoms of congestive heart failure, pulmonary edema, and cardiomegaly on chest x-ray, elevated levels of B-type natriuretic peptide (BNP), and an echocardiogram demonstrating preserved systolic function with Doppler evidence of impaired left ventricular relaxation. She responded to medical therapy for heart failure. To date, no other investigators have described isolated diastolic dysfunction as a cause of peripartum cardiomyopathy. A 42-year-old woman had a history of pulmonary edema within weeks following 2 uneventful previous pregnancies. The patient became pregnant again and was cared for throughout pregnancy in both the high-risk obstetric clinic and the cardiology section. This pregnancy was uncomplicated, and there was no evidence of gestational hypertension. The patient underwent a cesarean section at another hospital for cephalopelvic disproportion. She developed dyspnea after delivery, was treated with furosemide, and was given metoprolol tartrate at discharge. One week later, she presented to another hospital with dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Blood pressure was 165/90 mm Hg, heart rate was 50 beats per minute, and respiratory rate was 22 breaths per minute. A computed tomographic scan ruled out a pulmonary embolus and demonstrated significant pulmonary edema. Her pro-BNP level was elevated at 775 pg/mL. She was transferred to our institution, where on arrival, her chest radiograph showed pulmonary edema (Figure 1). An echocardiogram showed no valvular abnormalities and demonstrated normal left ventricular ejection fraction (Figure 2), fractional shortening, and dimensions. The left ventricular filling pattern showed reduced mitral annular early diastolic velocity on Doppler tissue imaging (Figure 3). Her heart failure resolved after treatment with an angiotensin-converting enzyme inhibitor, diuretic, and later a β-adrenergic receptor blocker. Chest radiograph demonstrating pulmonary edema. Apical 4-chamber view with normal left ventricular systolic function. A, end diastole. B, end systole. Tissue Doppler imaging of septal mitral annulus demonstrating reduced early diastolic velocity. The criteria for diagnosis of peripartum cardiomyopathy are: (1) development of cardiac failure in the last month of pregnancy or within 5 months of delivery; (2) absence of an identifiable cause for the cardiac failure; (3) absence of recognizable heart disease before the last month of pregnancy; and (4) an ejection fraction of <45% and/or an M-mode fractional shortening of <30% and an end-diastolic dimension >2.7 cm/m2.1 This modified definition assumes that women with peripartum cardiomyopathy have systolic dysfunction as the source of their heart failure. To date, no other investigators have described peripartum cardiomyopathy in the absence of a reduced ejection fraction. Heart failure with preserved ejection fraction is a clinical syndrome characterized by the signs and symptoms of heart failure, a preserved ejection fraction, and abnormal diastolic function.2 At the bedside, it is difficult to differentiate heart failure due to systolic dysfunction from that caused by diastolic dysfunction. Two-dimensional echocardiography can accurately measure the left ventricular ejection fraction, and the left ventricular diastolic function can be determined by either Doppler-derived mitral and pulmonary venous flow velocities or Doppler tissue imaging. Because abnormal systolic function is one of the criteria for diagnosis, peripartum patients with heart failure who have normal ejection fractions are excluded from series of women with peripartum cardiomyopathy. However, as our case demonstrates, peripartum cardiomyopathy can and does result from diastolic dysfunction. The morbidity, mortality, and risk of recurrence during future pregnancies are unknown in this group.

Peripartum Cardiomyopathy Presenting at Cesarean Section - A case report -

Peripartum cardiomyopathy (PPCM) is defined as the onset of acute heart failure without any demonstrable cause in the last trimester of pregnancy or within the first 6 months after delivery. It is characterized by ventricular dilatation and poor ventricular contractility but it is often unrecognized because the symptoms of normal pregnancy commonly mimic those of mild heart failure. The incidence varies from 1 in 1,300 to 1 in 15,000 pregnancies. We encountered a patient, who developed sudden pulmonary edema during an elective cesarean section. Echocardiography performed after the surgery showed a low ejection fraction (20%). The patient was treated with diuretics and inotropic agents and mechanical ventilation with positive end-expiratory pressure. She was discharged uneventfully on the postoperative 11th day.

Peripartum cardiomyopathy: review of the literature.

Peripartum cardiomyopathy (PPCM) is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Clinical presentation of PPCM is similar to that of systolic heart failure from any cause, and it can sometimes be complicated by a high incidence of thromboembolism. Prior to the availability of echocardiography, diagnosis was based only on clinical findings. Recently, inclusion of echocardiography has made diagnosis of PPCM easier and more accurate. Its etiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. Prompt recognition with institution of intensive treatment by a multidisciplinary team is a prerequisite for improved outcome. Conventional treatment consists of diuretics, β blockers, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Cardiac transplantation may be necessary in patients not responding to conventional and newer therapeutic strategies. The role of the anesthesiologist is important in perioperative and intensive care management. 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 heart function. This article aims to provide a comprehensive updated review of PPCM covering etiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis, while stressing areas that require further research.

Peripartum Cardiomyopathy Presenting with Repetitive Monomorphic Ventricular Tachycardia

A 30-year-old asymptomatic pregnant woman at 38 weeks' gestation was noticed to have repetitive monomorphic ventricular tachycardia. A dilated left ventricle with moderately reduced systolic function was found on echocardiographic examination. To the best of our knowledge, a case of peripartum cardiomyopathy presenting with repetitive monomorphic ventricular tachycardia has not been previously reported.

Peripartum Cardiomyopathy Presenting as an Acute Myocardial Infarction

Peripartum Cardiomyopathy Presenting as an Acute Myocardial Infarction

ED echocardiography for peripartum cardiomyopathy

Although peripartum cardiomyopathy is uncommon, emergency physicians should be knowledgeable of it because of its high morbidity and mortality. Emergency physicians should be alert to the fact that the clinical presentation of peripartum cardiomyopathy is nonspecific. Its clinical manifestations are found in other medical conditions that can present in the late prepartum or postpartum patient. We present a case of peripartum cardiomyopathy that illustrates how its nonspecific respiratory signs and symptoms led to an initial diagnosis of pulmonary embolism. The case also highlights the need for echocardiography in the evaluation of peripartum cardiomyopathy. We discuss the clinical presentation, diagnosis, and treatment of peripartum cardiomyopathy.

Peripartum cardiomyopathy: a review of the literature.

Peripartum cardiomyopathy (PPCM) is a poorly characterized, rare form of cardiomyopathy. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The presentation is similar to other forms of congestive heart failure; the diagnosis of PPCM should not be considered until other causes of cardiac dysfunction are ruled out. Echocardiography is central to diagnosis. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Intensivists and anesthesiologists should be consulted to assist with management in complicated cases. Management of PPCM is essentially supportive. Prognosis is poor, although cardiac transplant is improving prognosis and should be considered when conventional therapy fails. Obstetricians & Gynecologists, Family Physicians After completion of this article, the reader will be able to understand the typical presentation of peripartum cardiomyopathy including adverse outcome predictors, to understand how to make the diagnosis of PPCM and how to manage it, and to understand the natural history of the disease.