Peripartum cardiomyopathy: Status 2018

Development and validation of an electrocardiographic artificial intelligence model for detection of peripartum cardiomyopathy

BACKGROUND

This study used electrocardiogram data in conjunction with artificial intelligence methods as a noninvasive tool for detecting peripartum cardiomyopathy.

OBJECTIVE

This study aimed to assess the efficacy of an artificial intelligence-based heart failure detection model for peripartum cardiomyopathy detection.

STUDY DESIGN

We first built a deep-learning model for heart failure detection using retrospective data at the University of Tennessee Health Science Center. Cases were adult and nonpregnant female patients with a heart failure diagnosis; controls were adult nonpregnant female patients without heart failure. The model was then tested on an independent cohort of pregnant women at the University of Tennessee Health Science Center with or without peripartum cardiomyopathy. We also tested the model in an external cohort of pregnant women at Atrium Health Wake Forest Baptist. Key outcomes were assessed using the area under the receiver operating characteristic curve. We also repeated our analysis using only lead I electrocardiogram as an input to assess the feasibility of remote monitoring via wearables that can capture single-lead electrocardiogram data.

RESULTS

The University of Tennessee Health Science Center heart failure cohort comprised 346,339 electrocardiograms from 142,601 patients. In this cohort, 60% of participants were Black and 37% were White, with an average age (standard deviation) of 53 (19) years. The heart failure detection model achieved an area under the curve of 0.92 on the holdout set. We then tested the ability of the heart failure model to detect peripartum cardiomyopathy in an independent University of Tennessee Health Science Center cohort of pregnant women and an external Atrium Health Wake Forest Baptist cohort of pregnant women. The independent University of Tennessee Health Science Center cohort included 158 electrocardiograms from 115 patients; our deep-learning model achieved an area under the curve of 0.83 (0.77-0.89) for this data set. The external Atrium Health Wake Forest Baptist cohort involved 80 electrocardiograms from 43 patients; our deep-learning model achieved an area under the curve of 0.94 (0.91-0.98) for this data set. For identifying peripartum cardiomyopathy diagnosed ≥10 days after delivery, the model achieved an area under the curve of 0.88 (0.81-0.94) for the University of Tennessee Health Science Center cohort and of 0.96 (0.93-0.99) for the Atrium Health Wake Forest Baptist cohort. When we repeated our analysis by building a heart failure detection model using only lead-I electrocardiograms, we obtained similarly high detection accuracies, with areas under the curve of 0.73 and 0.93 for the University of Tennessee Health Science Center and Atrium Health Wake Forest Baptist cohorts, respectively.

CONCLUSION

Artificial intelligence can accurately detect peripartum cardiomyopathy from electrocardiograms alone. A simple electrocardiographic artificial intelligence-based peripartum screening could result in a timelier diagnosis. Given that results with 1-lead electrocardiogram data were similar to those obtained using all 12 leads, future studies will focus on remote screening for peripartum cardiomyopathy using smartwatches that can capture single-lead electrocardiogram data.

A new risk score for the assessment of outcomes for Chinese patients with peripartum cardiomyopathy

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a potentially life-threatening complication of pregnancy, but identifying patients at higher risk of this condition remains difficult.

OBJECTIVES

We conducted a study to identify new risk factors associated with PPCM and predictors of poor outcomes.

METHODS

This retrospective analysis included a total of 44 women with PPCM. As a control group, 79 women who gave birth around the same time as the PPCM patients and who did not have organic disease were included. A multivariate regression analysis was conducted to identify risk factors associated with PPCM and with delayed recovery.

RESULTS

All PPCM patients were discharged within 28 days. In comparison to the control group, PPCM patients had higher rates of preeclampsia (20.4% vs. 1.27%, P<0.001), autoimmune disease (27.3% vs. 11.4%, P = 0.018), and cesarean delivery with preterm labor (31.8% vs. 17.7%, P = 0.037). The neonates of PPCM patients had lower birth weight (2.70±0.66 kg vs. 3.21±0.57 kg, P<0.001). PPCM patients had higher levels of C-reactive protein, d-dimer, brain natriuretic peptide (BNP), and serum phosphorus, but lower levels of albumin and serum calcium (all P<0.001). In all patients with PPCM, the left ventricular ejection fraction (LVEF) returned to normal (≥50%) within 28 days after admission. Subjects with early recovery (n = 34) had lower BNP than those with delayed recovery (n = 10) (649.7 ± 526.0 pg/mL vs. 1444.1 ± 1040.8 pg/mL, P = 0.002). Multivariate regression led to a three-point score system to predict PPCM (1 point each for the presence of pericardial effusion, left ventricular dilatation, and d-dimer level ≥0.5 μg/mL). At a cutoff of ≥2, this scoring system predicted delayed recovery with 95.5% sensitivity and 96.1% specificity. The negative predictive value was 97.4% and the positive predictive value was 93.3%. Binary logistic regression indicated that PPCM patients with pulmonary hypertension, lower hemoglobin, or worse LVEF tended to require longer hospital stay (minimum 14 days).

CONCLUSIONS

A risk score that consists of pericardial effusion, left ventricular dilatation, and d-dimer level ≥ 0.5 μg/mL could help streamline the diagnosis of PPCM prior to confirmatory investigations. Moreover, a risk score that consists of pulmonary hypertension, lower hemoglobin and worse LVEF could help to predict poor outcomes in PPCM patients.

Seleno-Metabolites and Their Precursors: A New Dawn for Several Illnesses?

Selenium (Se) is an essential element for human health as it is involved in different physiological functions. Moreover, a great number of Se compounds can be considered potential agents in the prevention and treatment of some diseases. It is widely recognized that Se activity is related to multiple factors, such as its chemical form, dose, and its metabolism. The understanding of its complex biochemistry is necessary as it has been demonstrated that the metabolites of the Se molecules used to be the ones that exert the biological activity. Therefore, the aim of this review is to summarize the recent information about its most remarkable metabolites of acknowledged biological effects: hydrogen selenide (HSe-/H2Se) and methylselenol (CH3SeH). In addition, special attention is paid to the main seleno-containing precursors of these derivatives and their role in different pathologies.

Staphylococcus-induced proliferative glomerulonephritis and cerebral hemorrhage - fatal complications in a young female with postpartum cardiomyopathy and an implanted left ventricular assist device: a case report and review of the literature

Background: The continuous-flow left ventricular assist device (CF-LVAD) is used to save the lives of patients in the final stage of congestive heart failure, replacing the pump function of the left ventricle. Although quality of life increases significantly, CF-LVAD-related complications might prove fatal, as in the case presented in this paper.Methods: A 20-year-old female, during her second pregnancy, presented with signs of heart failure. Emergency caesarean section was necessary to save the baby, but peripartum cardiomyopathy developed in the mother. The use of an implantable cardioverter-defibrillator (ICD) was necessary 5 years later. As the clinical progression was unfavorable under medical treatment, with the patient reaching INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) Profile 1 (refractory cardiogenic shock), the treatment of choice was the implantation of a CF-LVAD.Results: After 3 years of follow-up (at the age of 28), the patient presented with a positive hemoculture for Staphylococcus aureus. Prolonged antibiotic therapy and attentive follow-up was prescribed. Although an effective antiplatelet and anticoagulant treatment was applied, and despite therapeutic values of prothrombin time and international normalized ratio (INR), the patient died as result of a fatal cerebral hemorrhage. The autopsy also revealed septic emboli, disseminated intravascular coagulation, and focal proliferative glomerulonephritis.Conclusions: Although the benefits of CF-LVAD are significant, bleeding episodes can be severe and LVAD-associated infection can trigger glomerular injury and increase mortality.

Unveiling the Mystery of Peripartum Cardiomyopathy: A Traditional Review

Peripartum cardiomyopathy (PPCM) can be classified as a variant of dilated cardiomyopathy identified usually within the first five months of delivery or during the last month of pregnancy. This condition presents as systolic heart failure. PPCM affects thousands of women in the United States each year. Even though it was first noticed in the 1800s, its etiology remains unknown. This study aims to review the pathophysiology and management of PPCM and explore the possible outcomes of peripartum cardiomyopathy. PPCM can lead to maternal death if diagnosis or treatment is delayed. Diagnosing PPCM has been challenging because it can be misdiagnosed or perceived as a sign of pregnancy since most of the symptoms of PPCM strongly match those within the typical pregnancy continuum and postpartum cycle. Patients' implications are fatal and carry a high mortality rate when PPCM is misdiagnosed or treatment is delayed. To accurately identify PPCM, using echocardiography, the left ventricular end-diastolic size and the ejection fraction should be measured to determine the severity of PPCM. Managing peripartum cardiomyopathy involves using traditional treatments for heart failure. Therapeutic recommendations are made depending on the patient's status (pregnancy, breastfeeding, postpartum) while considering the drug-safety profiles before administration. Some other treatments have also been used to control PPCM depending on how severe it has become; for example, antiarrhythmics have been used to treat cardiac arrhythmias when they ensue. In extreme cases, mechanical assistance and transplantation could be required. Based on the proposed pathophysiology involving the 16kDA anti-angiogenic sub-fragment, bromocriptine may be used even though it still needs more assessment due to limited evidence.

Using PubMed as a major search resource, a thorough analysis of publications was carried out after incorporating this review's inclusion and exclusion criteria. A total of 455,141 publications were found using keywords and keyword combinations. With a careful selection of articles, 31 publications provided relevant information on our primary endpoint. All articles in this examination were chosen without limitation to the type of study, including clinical trials, review articles, meta-analyses, and so on. Our review suggests that, based on factors such as early detection and management, disease severity, ethnicity, and quality of patient care, patients with PPCM presented different outcomes and prognosis. However, despite PPCM's high mortality rate and its risk of recurrence, most patients tend to recover within six months of disease onset.

Psychosocial Adjustment and Quality of Life in Patients With Peripartum Cardiomyopathy

BACKGROUND

Psychological distress can adversely affect heart failure prognosis, yet the immediate and ongoing challenges faced by women diagnosed with peripartum cardiomyopathy (PPCM) are not well studied.

OBJECTIVE

We examined psychological distress and quality of life in a large, national sample of patients with PPCM and evaluated whether these characteristics differ among newly diagnosed (0-1 year), short-term (2-4 years), and long-term (5-10 years) survivors.

METHODS

One hundred forty-nine patients with PPCM (mean age, 33.9 ± 5.0 years) recruited from a web-based registry completed questionnaires about generalized anxiety (Generalized Anxiety Disorder-7), cardiac anxiety (Cardiac Anxiety Questionnaire [CAQ]), health status (Medical Outcomes Study Short-Form 12 [SF-12] Health Survey), and PPCM-specific quality-of-life concerns. Group differences were evaluated using multivariate statistics with adjustments for disease severity and psychiatric history.

RESULTS

Generalized anxiety symptoms higher than the clinical cutoff were reported by 53% of patients with PPCM. Mean scores on the CAQ (1.9 ± 0.7) and CAQ subscale scores (cardiac-specific fear [2.1 ± 0.8], avoidance [1.7 ± 0.9], and heart-focused attention [1.6 ± 0.8]) were elevated in the overall sample. Psychological symptoms and quality-of-life concerns were generally similar across patients except for cardiac avoidance, which was significantly higher in newly diagnosed women after adjustments for disease severity (P = .05) and psychiatric history (P = .01). Peripartum cardiomyopathy-specific quality-of-life concerns were also prevalent; however, group differences were nonsignificant (P = .07).

CONCLUSIONS

Generalized anxiety, cardiac anxiety, and quality-of-life concerns are prevalent among patients with PPCM at all stages of recovery. Psychological issues may be an underrecognized aspect of women's recovery from PPCM.

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.

CE: Gestational Hypertension, Preeclampsia, and Peripartum Cardiomyopathy: A Clinical Review

Gestational hypertension, preeclampsia, and peripartum cardiomyopathy are among the most common and often severe pregnancy-specific cardiovascular diseases (CVDs) and causes of complications in pregnancy. This clinical review provides nurses with an overview of pregnancy-specific CVDs, outlines their pathophysiology, and discusses risk factors and assessment. It describes management interventions according to timing: the antepartum, intrapartum, and postpartum phases are each addressed.

Peripartum cardiomyopathy: Status 2018

Peripartum cardiomyopathy is a rare cardiac condition, overall. However, in certain populations can be found frequently enough and the signs, symptoms, and management should be readily understood. Here we provide an updated overview of this topic.