Peripartum cardiomyopathy: a comprehensive review

Comprehensive review of pulmonary vein stenosis post-atrial fibrillation ablation: diagnosis, management, and prognosis

Pulmonary vein stenosis (PVS) can occasionally occur in the follow-up after pulmonary vein isolation (PVI) for atrial fibrillation (AF). During PVI, ablation is performed at the PV ostium or distal part, leading to tissue damage. This damage can result in fibrosis of the necrotic myocardium, proliferation, and thickening of the vascular intima, as well as thrombus formation, further advancing PVS. Mild-to-moderate PVS often remains asymptomatic, but severe PVS can cause symptoms, such as dyspnea, cough, fatigue, decreased exercise tolerance, chest pain, and hemoptysis. These symptoms are due to pulmonary hypertension and pulmonary infarction. Imaging evaluations such as contrast-enhanced computed tomography are essential for diagnosing PVS. Early suspicion and detection are necessary, as underdiagnosis can lead to inappropriate treatment, disease progression, and poor outcomes. The long-term prognosis of PVS remains unclear, particularly regarding the impact of mild-to-moderate PVS over time. PVS treatment focuses on symptom management, with no established definitive solutions. For severe PVS, transcatheter PV angioplasty is performed, though the risk of restenosis remains high. Restenosis and reintervention rates have improved with stent implantation compared with balloon angioplasty. The role of subsequent antiplatelet therapy remains uncertain. Dedicated evaluation is essential for accurate diagnosis and appropriate management to avoid significant long-term impacts on patient outcomes.

Conservative Management of a Case of Peripartum Cardiomyopathy in a Young Multigravida

Peripartum cardiomyopathy (PPCM) is a rare disorder that generally affects the elderly multigravida females. It is a type of dilated cardiomyopathy that generally affects the last trimester of pregnancy or early postpartum period. Several risk factors are associated with the development of PPCM. Even though PPCM has greater morbidity, if managed promptly, it can be reverted with minimal morbidity or mortality. We present a case of a young woman, multigravida, with moderate anemia corrected, who was taken for emergency lower segment cesarean section, without previous cardiac evaluation, and ended up with pulmonary edema intraoperatively. Later on, her evaluation was done which came out to be PPCM. She was managed conservatively thereafter with no significant morbidity and a good maternal and perinatal outcome. We should be alert in diagnosing a case of PPCM with prompt treatment to reduce mortality. Cardiovascular conditions cause approximately 26 percent of pregnancy-related deaths which include valvular heart disease and congenital heart disease. Appropriate diagnosis and management are necessary for preventing mishaps.

Peripartum cardiomyopathy in an elderly woman: A case report

Cardiomyopathy accounts for 11.5% cause of pregnancy-related deaths. The causes of peripartum cardiomyopathy (PPCM) are unknown, including predisposing factors such as abnormal response to the greater hemodynamic burden of pregnancy, viral myocarditis, malnutrition, inflammation, and apoptosis. Elderly women, twin gestation, preeclampsia, smoking, and anemia are potential high-risk factors for PPCM. Here, rare case of a patient is described that presented with complaints of breathlessness, cough, and symptoms of heart failure and was diagnosed early as PPCM based on 2D echocardiography and was managed with medical therapy and timely delivery of fetus. Symptomatic relief of symptoms was relieved by diuretics, inotropic drugs, and beta-blockers. The left ventricular ejection fraction increased eventually over 3 weeks and now the patient is a follow-up case since two years from the time of episode. In conclusion, PPCM is rare, which requires prompt management and heightened mindfulness; therefore, early detection and timely treatment can reduce maternal mortality.

Reversible Cerebral Vasoconstriction Syndrome and Ischemic Stroke Secondary to Peripartum Cardiomyopathy - Report a Rare Case

Acute cardioembolic stroke is a rare presentation of peripartum cardiomyopathy. We present an unusual case of peripartum cardiomyopathy, that subsequently developed cardioembolic ischemic stroke and reversible cerebral vasospasms. 

A 26-year-old G1P1 caucasian woman presented to the emergency department 10 days after a spontaneous vaginal delivery with the clinical and physical presentation of acute heart failure. Brain natriuretic peptide (BNP) level was >8000 pg/mL. Transthoracic echocardiogram (TTE) demonstrated global left ventricular hypokinesis, reduced ejection fraction (EF) 22% with grade I diastolic dysfunction and apical thrombus. On hospital day two of her heart failure exacerbation admission, a code stroke was activated for aphasia and confusion. She received an IV tissue plasminogen activator (tPA) and underwent a mechanical thrombectomy. On hospital day three, she developed worsening of neurological symptoms, and a computed tomography (CT) angiogram revealed vasospasm in the region of the left middle cerebral artery (MCA), which subsequently resulted in nimodipine therapy. Furthermore, her hospital course was complicated by persistent hypotension, and with our concern for vasospasm that was noted in the CT angiogram instead of guideline-directed therapy for heart failure, digoxin was given to control heart rate and to improve cardiac output. Ultimately, her neurological symptoms improved, and she was discharged on hospital day 10.

This case highlights the combination of rare presentations - postpartum cardiomyopathy, ischemic stroke, and reversible cerebral vasospasms, which suggests that the time and size of the stroke are of the essence in terms of promptness of aggressive treatment.

Recent findings on hyperprolactinemia and its pathological implications: a literature review

The prolactin hormone (PRL) is often secreted by lactotrophic cells of the anterior pituitary and has been shown to play a role in various biological processes, including breast feeding and reproduction. The predominant form of this hormone is the 23 kDa form and acts through its receptor (PRLR) on the cell membrane. This receptor is a member of the superfamily of hematopoietic/cytokine receptors. PRL also has a 16 kDa subunit with anti-angiogenic, proapoptotic, and anti-inflammatory effects which is produced by the proteolytic breakdown of this hormone under oxidative stress. Although the common side effects of hyperprolactinemia are exerted on the reproductive system, new studies have shown that hyperprolactinemia has a wide variety of effects, including playing a role in the development of autoimmune diseases and increasing the risk of cardiovascular disease, peripartum cardiomyopathy, and diabetes among others. The range of PRL functions is increasing with the discovery of multiple sites of PRL secretion as well as PRLR expression in various tissues. This review summarizes current knowledge of the biology of PRL and its receptor, as well as the role of PRL in human pathophysiology.

Antithrombotic Treatment in Cardiomyopathies

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Cardiomyopathies are a heterogeneous group of heart muscle diseases and important cause of heart failure with reduced or preserved ejection fraction. Although there is an increasing body of evidence on the incidence, pathophysiology, and natural history of heart failure (HF) in cardiomyopathies, certain aspects of the therapeutic strategies remain unclear. More particularly, there is no consensus if to whether antithrombotic therapy has a favorable risk: benefit ratio in reducing thromboembolic event rate in patients with cardiomyopathies without suffering from primary valvular disease or atrial fibrillation. Although the observational data on increased venous thromboembolic risk are supported by multiple pathophysiological mechanisms, the role of antithrombotic therapy in these patients remains unclear. This review article provides an overview of epidemiologic, pathophysiologic, clinical, and therapeutic data for the prevention of thromboembolism in heart failure due to cardiomyopathies.

Atrial fibrillation and non-ischaemic cardiomyopathy in the peripartum period

A 31-year-old primiparous woman with a history of bigeminy as a teenager developed atrial fibrillation with rapid ventricular response during elective caesarean section. Initial postoperative medical management was undertaken on the maternal high dependency unit and involved the administration of beta-blockers and digoxin. On postoperative day 1 the patient was transferred to the coronary care unit where she subsequently required synchronised direct current cardioversion to restore sinus rhythm. The patient remained on the coronary care unit for 5 days before discharge. Magnetic resonance imaging undertaken 6 weeks postpartum showed non-ischaemic cardiomyopathy. In this report, we discuss tachycardia-induced and peripartum cardiomyopathies, along with their potential underlying pathologies, incidence and associated morbidity. We describe potential pharmacological therapies including beta-blockers and angiotensin-converting enzyme inhibitors, as well as the implications of such medications for breastfeeding mothers. Patients presenting with palpitations in the antenatal period should receive prompt investigation including electrocardiography with ambulatory monitoring considered for those with persistent symptoms. Anyone with a proven cardiac arrhythmia should undergo echocardiography. This report illustrates the importance of the investigation of the symptoms of arrhythmia during pregnancy and emphasises the role of multidisciplinary working in the management of obstetric patients with complex medical comorbidity.

Rhinovirus-associated dilated cardiomyopathy

Rhinovirus is the main cause of the common cold. There is little to no published literature of rhinoviral associated myocarditis. We report a rare case of rhinovirus infection in a patient with myocarditis leading to dilated cardiomyopathy. Infection is an established cause of myocarditis. Prodromal "flu-like" symptoms in a young patient with unexplained heart failure should raise concern for viral myocarditis. Diagnosis is often made by clinical presentation and not by endomyocardial biopsy due to invasiveness. Polymerase chain reaction is a rapid test that supports the diagnosis and may elucidate the role of the virus in myocarditis. Defining causes and mechanisms leading to this severe cardiovascular condition may prove critical to targeted therapy. Physician should be aware that rhinovirus as a possible pathogen for severe myocarditis and dilated cardiomyopathy.

Three female patients with Danon disease presenting with predominant cardiac phenotype: a case series

Background

Danon disease is a rare X-linked multisystemic disorder that has primarily been described in male patients.

Case summary

We present three female patients with Danon disease with a predominantly cardiac phenotype in whom disease onset and expression was very different from that of male patients. Case 1 was first admitted for acute heart failure and then readmitted a few months later for cardiac shock, necessitating mechanical support, and heart transplantation. Case 2 had complex arrhythmias for which many antiarrhythmic drugs were tried with only limited success. Her disease accelerated after her first pregnancy, and she showed reduced left ventricular function and dilated cardiomyopathy. Case 3 was referred for near syncope and ablated for an accessory pathway; she had extensive left ventricular hypertrophy. In all three cases, a final diagnosis of Danon disease was only made after genetic testing that identified a causal variant in the lysosome-associated membrane protein 2 gene.

Discussion

Danon disease in female patients is a challenging diagnosis that may not be identified until genetic testing has been performed.

A Retrospective Evaluation of Risk of Peripartum Cardiac Dysfunction in Survivors of Childhood, Adolescent and Young Adult Malignancies

Long-term survivors of childhood, adolescent and young adult (AYA) malignancies with past exposure to potentially cardiotoxic treatments are at risk of peripartum cardiac dysfunction. Incidence and risk factors for peripartum cardiac dysfunction and maternal cardiac outcomes in this population were investigated. Eligible long-term survivors were aged <30 years at cancer diagnosis, with ≥1 pregnancy occurring ≥5 years after diagnosis. "Peripartum" cardiac events were defined as occurring within pregnancy or ≤5months after delivery. Cardiac events were classified "symptomatic" or "subclinical". "Peripartum cardiomyopathy" (PPCM) was defined as symptomatic dysfunction without prior cardiac dysfunction. Of 64 eligible women, 5 (7.8%) had peripartum cardiac events: 3 symptomatic, 2 subclinical. Of 110 live births, 2 (1.8%, 95% CI 0.2-6.4) were defined as PPCM: Significantly greater than the published general population incidence of 1:3000 (p < 0.001), representing a 55-fold (95% CI 6.6-192.0) increased risk. Risk factor analyses were hypothesis-generating, revealing younger age at cancer diagnosis and higher anthracycline dose. Postpartum, cardiac function of 4 women (80%) failed to return to baseline. In conclusion, peripartum cardiac dysfunction is an uncommon but potentially serious complication in long-term survivors of paediatric and AYA malignancies previously treated with cardiotoxic therapies. Peripartum cardiac assessment is strongly recommended for at-risk patients.

Peripartum cardiomyopathy and ventricular thrombus: A case report and review of literature

Peripartum cardiomyopathy (PPCMP) is a rare and life-threatening condition. Intracardiac thrombus is characteristically associated with increased adverse events, mortality, and a high risk of thromboembolic events, and has been associated with PPCMP. Early diagnosis and treatment play a critical role. Although echocardiography is the first-line diagnostic method, other imaging modalities may provide useful information in appropriate patients. Presently described is a case in which an apical intracardiac thrombus coexisting with PPCMP was identified and managed using multimodality imaging studies.

Anticoagulation Therapy in Specific Cardiomyopathies: Isolated Left Ventricular Noncompaction and Peripartum Cardiomyopathy

In 2 distinct entities, left ventricular noncompaction (LVNC) and peripartum cardiomyopathy (PPCM), routine anticoagulation therapy is often used in current practices. However, our systematic review showed that LVNC itself was not associated with the increase in thromboembolism event rates and therapeutic anticoagulation therapy should not be considered only for LVNC, unless there is risk factor for thromboembolism. Current literature justifies prophylactic therapeutic anticoagulation in LVNC with low left ventricular ejection fraction (EF < 40%) and/or atrial fibrillation. Although not specifically studied, the presence of intracardiac thrombi by echocardiography or other imaging studies should also prompt anticoagulation therapy. There is limited evidence available for the use of anticoagulation in patients with PPCM, but our systematic review showed that anticoagulation should be recommended only for patients with PPCM especially with an EF < 35% until EF is recovered, as well as for patients with PPCM treated with bromocriptine.

De novo left ventricular non-compaction accompanied by severe mitral valve failure in a young pregnant

De novo left ventricular non-compaction is a rare pathology in the peripartum period. To the best of our knowledge, pregnancy-induced cardiomyopathy accompanied by severe mitral valve insufficiency requiring surgery during pregnancy has not been previously reported. Herein, we report the first postpartum case of de novo left ventricular non-compaction who underwent mitral valve repair.

Three Cases of Peripartum Cardiomyopathy

Dyspnoea and dizziness are very common presentations in the emergency department. We describe three female patients complaining of dyspnoea and dizziness during their postpartum period. Clinical manifestations and diagnosis of peripartum cardiomyopathy is discussed.

Imaging of Cardiovascular Disease in Pregnancy and the Peripartum Period

OPINION STATEMENT

Cardiovascular disease is an important cause of morbidity and mortality during pregnancy and the postpartum period. During pregnancy, the cardiovascular system undergoes extensive hemodynamic, hormonal, and microstructural changes which may exacerbate a preexisting underlying cardiovascular condition or predispose to cardiovascular complications not typically seen in young healthy women. Such conditions include spontaneous coronary artery dissection, atherosclerotic coronary artery disease, and peripartum cardiomyopathy. When evaluating this patient population, the diagnostic strategy should be tailored to specifically assess this distinct disease spectrum. The choice of imaging techniques must also consider potential risks to both the mother and child; a unique challenge of diagnostic imaging during pregnancy. The risk of radiation from radiography, computed tomography, and nuclear medicine imaging; iodinated and gadolinium-based contrast media for computed tomography and magnetic resonance imaging respectively; and heat deposition from sonography are of special importance during pregnancy. A thorough understanding of pregnancy-specific cardiovascular complications and the capabilities and risks of available diagnostic imaging modalities is crucial to appropriately manage the pregnant patient.

Clinical outcomes of peripartum cardiomyopathy: a 15-year nationwide population-based study in Asia

Peripartum cardiomyopathy (PPCM) is the development of heart failure during late pregnancy to months postpartum with potential fatal outcome. However, the disease is not well-studied in Asia.We aimed to investigate the epidemiology and clinical outcomes of PPCM in Taiwan.Electronic medical records were retrieved from Taiwan National Health Insurance Research Database from 1997 to 2011. Patients with PPCM were separated into 3 groups based on the timing of diagnosis. Early: PPCM diagnosed first to ninth month of pregnancy. Traditional: PPCM diagnosed last month of pregnancy till fifth month post-delivery. Late: PPCM diagnosed sixth to twelfth month post-delivery. Primary outcomes defined as cardiac death, all-cause mortality, and major adverse cardiovascular events (MACE) within 1 year.A total of 3,506,081 deliveries during 1997 to 2011 were retrieved and 925 patients with PPCM were identified. Overall incidence of PPCM was 1:3,790 during the 15 years. Early, Traditional, and Late group each had 88, 742, and 95 patients. Cardiac death occurred in 31 patients, all-cause mortality in 72 patients, and MACE in 65 patients. Late group had 2- to 3-fold event rates in cardiac death, all-cause mortality, and MACE compared with Early and Traditional groups. Cumulative incidence showed significant differences for cardiac death (P = .0011), all-cause mortality (P = .0031), and MACE (P = .0014) among 3 groups. Multivariate Cox model showed Late group had significantly worse outcomes after adjusted for clinical variables compared with 2 other groups.Our study is the largest national cohort among Asian countries that showed timing of diagnosis of PPCM had different outcomes. Late diagnosis portended significantly increased morbidity and mortality, even after adjusted for clinical variables.

A young puerperal woman presenting to emergency department with severe dyspnea

Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy presenting with heart failure (HF) secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of HF is found. The symptoms and signs of this rare disorder mimic those of the physiological changes of pregnancy or other cardiovascular diseases. Consequently, its diagnosis is frequently delayed, which worsens an already poor prognosis. Here, we report a young adult who was diagnosed with PPCM, early, with the help of focused cardiac ultrasonography, performed after presenting to the emergency department with nonspecific respiratory complaints, including dyspnea and hemoptysis, which suggested at first pulmonary embolism.

Cardiac telomere length in heart development, function, and disease

Telomeres are repetitive nucleoprotein structures at chromosome ends, and a decrease in the number of these repeats, known as a reduction in telomere length (TL), triggers cellular senescence and apoptosis. Heart disease, the worldwide leading cause of death, often results from the loss of cardiac cells, which could be explained by decreases in TL. Due to the cell-specific regulation of TL, this review focuses on studies that have measured telomeres in heart cells and critically assesses the relationship between cardiac TL and heart function. There are several lines of evidence that have identified rapid changes in cardiac TL during the onset and progression of heart disease as well as at critical stages of development. There are also many factors, such as the loss of telomeric proteins, oxidative stress, and hypoxia, that decrease cardiac TL and heart function. In contrast, antioxidants, calorie restriction, and exercise can prevent both cardiac telomere attrition and the progression of heart disease. TL in the heart is also indicative of proliferative potential and could facilitate the identification of cells suitable for cardiac rejuvenation. Although these findings highlight the involvement of TL in heart function, there are important questions regarding the validity of animal models, as well as several confounding factors, that need to be considered when interpreting results and planning future research. With these in mind, elucidating the telomeric mechanisms involved in heart development and the transition to disease holds promise to prevent cardiac dysfunction and potentiate regeneration after injury.

Heart Failure with Myocardial Recovery - The Patient Whose Heart Failure Has Improved: What Next?

In an important number of heart failure (HF) patients substantial or complete myocardial recovery occurs. In the strictest sense, myocardial recovery is a return to both normal structure and function of the heart. HF patients with myocardial recovery or recovered ejection fraction (EF; HFrecEF) are a distinct population of HF patients with different underlying etiologies, demographics, comorbidities, response to therapies and outcomes compared to HF patients with persistent reduced (HFrEF) or preserved ejection fraction (HFpEF). Improvement of left ventricular EF has been systematically linked to improved quality of life, lower rehospitalization rates and mortality. However, mortality and morbidity in HFrecEF patients remain higher than in the normal population. Also, persistent abnormalities in biomarker and gene expression profiles in these patients lends weight to the hypothesis that pathological processes are ongoing. Currently, there remains a lack of data to guide the management of HFrecEF patients. This review will discuss specific characteristics, pathophysiology, clinical implications and future needs for HFrecEF.

Peripartum cardiomyopathy, place of drug therapy, assist devices, and outcome after left ventricular assistance

Peripartum cardiomyopathy remains a challenging obstetric and cardiologic emergency. We report 5 interesting cases of peripartum cardiomyopathy with different clinical courses, with 3 patients requiring left ventricular assist device implantation. One patient underwent pump explantation and aortic balloon valvuloplasty postsurgery. Two patients improved with the medical treatment alone without the need of assistance. We will review main important related issues.

Symptoms in women with Peripartum Cardiomyopathy: A mixed method study

OBJECTIVE

Peripartum Cardiomyopathy is a form of cardiac disease often associated with cardiac failure, occurring in late pregnancy or after childbirth. The anatomical and physiological changes in the mother associated with normal pregnancy are profound, and this may result in symptoms and signs that overlap with Peripartum Cardiomyopathy, leading to missed or delayed diagnosis. Women's experiences of Peripartum Cardiomyopathy symptoms remain poorly studied. The aim of this study was to explore and describe women's experiences of symptoms in Peripartum Cardiomyopathy.

DESIGN

A triangulation of methods with individual interviews and data from medical records.

SETTING

Mothers with Peripartum Cardiomyopathy diagnosis were recruited from Western Sweden as a part of research project.

PARTICIPANTS

19 women were interviewed and medical records were reviewed by authors.

DATA ANALYSIS

All interview transcripts were analysed using qualitative inductive content analysis to identify key themes.

RESULTS

The main theme, meaning of onset and occurrence of symptoms is captured in the metaphor: being caught in a spider web, comprising subthemes, invasion of the body by experienced symptoms and feeling of helplessness. Symptoms related to Peripartum Cardiomyopathy started for 17 women during pregnancy and in two post partum and time from symptoms to diagnosis varied between three and 190 days (median 40). The physical symptoms were:shortness of breath, excessive fatigue and swelling, bloatedness, nausea, palpitation, coughing, chest tightness, bodily pain, headache, fever, tremor, dizziness, syncope, restless and tingly body and reduced urine output. Emotional symptoms were: fear, anxiety, feelings of panic, and thoughts of impending death.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Symptoms of Peripartum Cardiomyopathy were debilitating, exhausting and frightening for the women interviewed in this study. Health care professionals responsible for the antenatal care, especially midwives, need skills to identify initial symptoms of Peripartum Cardiomyopathy for early referral and treatment by a specialist. In order to give optimal care more research is needed to show how to improve midwives' knowledge of Peripartum Cardiomyopathy.

Molecular mechanisms of peripartum cardiomyopathy: A vascular/hormonal hypothesis

Peripartum cardiomyopathy (PPCM) is characterized by the development of systolic heart failure in the last month of pregnancy or within the first 5 months postpartum. The disease affects between 1:300 and 1:3000 births worldwide. Heart failure can resolve spontaneously but often does not. Mortality rates, like incidence, vary widely based on location, ranging from 0% to 25%. The consequences of PPCM are thus often devastating for an otherwise healthy young woman and her newborn. The cause of PPCM remains elusive. Numerous hypotheses have been proposed, with mixed supporting evidence. Recent work has suggested that PPCM is a vascular disease, triggered by the profound hormonal changes of late gestation. We focus here on these new mechanistic findings, and their potential implication for understanding and treating PPCM.

Cardiomyopathy During Pregnancy

Cardiomyopathy is an acquired cardiac disorder that, although rare, accounts for a rising proportion of reported pregnancy-related deaths in the United States. During pregnancy, cardiomyopathy may be divided into 2 groups. The first group is peripartum cardiomyopathy; the second group is stratified according to 3 classically defined pathophysiologic presentations: hypertrophic, dilated, or restrictive. Within this second group, the cardiomyopathy can be either idiopathic or due to a specific identified cause. This disorder poses significant risks of morbidity and/or mortality to the pregnant woman and fetus/neonate. This article describes types of cardiomyopathy during pregnancy, perinatal risks, and general management principles with a focus on intrapartum care. Hemodynamic and oxygen transport data are presented to illustrate interpretation of patient assessment findings and the effects of interventions for abnormal maternal and fetal findings.

Amniotic fluid embolism pathophysiology suggests the new diagnostic armamentarium: β-tryptase and complement fractions C3-C4 are the indispensable working tools

Amniotic fluid embolism (AFE) is an uncommon obstetric condition involving pregnant women during labor or in the initial stages after delivery. Its incidence is estimated to be around 5.5 cases per 100,000 deliveries. Therefore, this paper investigated the pathophysiological mechanism, which underlies AFE, in order to evaluate the role of immune response in the development of this still enigmatic clinical entity. The following databases (from 1956 to September 2014) Medline, Cochrane Central, Scopus, Web of Science and Science Direct were used, searching the following key words: AFE, pathophysiology, immune/inflammatory response, complement and anaphylaxis. The main key word “AFE” was searched singularly and associated individually to each of the other keywords. Of the 146 sources found, only 19 were considered appropriate for the purpose of this paper. The clinical course is characterized by a rapid onset of symptoms, which include: acute hypotension and/or cardiac arrest, acute hypoxia (with dyspnoea, cyanosis and/or respiratory arrest), coagulopathies (disseminated intravascular coagulation and/or severe hemorrhage), coma and seizures. The pathology still determines a significant morbidity and mortality and potential permanent neurological sequelae for surviving patients. At this moment, numerous aspects involving the pathophysiology and clinical development are still not understood and several hypotheses have been formulated, in particular the possible role of anaphylaxis and complement. Moreover, the detection of serum tryptase and complement components and the evaluation of fetal antigens can explain several aspects of immune response.

Right ventricular outflow tract tachycardia worsened during pregnancy

We report the case of a 35 years old woman without underlying heart disease who was diagnosed with a right ventricular outflow tract tachycardia worsened during pregnancy. The diagnosis of ventricular tachycardia was made early in her pregnancy course but the patient had symptoms three months earlier. Her disease course was marked by rhythmic storms during the second trimester of pregnancy that led to three hospitalizations accounting for about two weeks in total. The combination of nadolol 80 mg and flecainide tablets 150 mg improved her rhythmic storms. Radiofrequency allowed a radical cure of this ventricular tachycardia. The patient is now asymptomatic 27 months after radiofrequency treatment.

Anesthetic management and outcomes of parturients with dilated cardiomyopathy in an academic centre

PURPOSE

This study examines the peripartum anesthetic management and outcomes of women with dilated cardiomyopathy in a large university medical centre over a seven-year period.

PRINCIPAL FINDINGS

Twenty-five women were included in this series, 18 with a new diagnosis of cardiomyopathy and seven with a history of cardiomyopathy. Sixteen patients (64%) identified themselves as African American, seven (28%) were Caucasian, and two patients (8%) were Hispanic. The median (range) gestational age at the time of a new diagnosis of cardiomyopathy was 29 (7-38) weeks. Eight women (32%) had New York Heart Association class III/IV symptoms at the time of delivery or in the immediate postpartum period. A multidisciplinary team of obstetricians, anesthesiologists, cardiologists, and pediatricians were involved in the care of these women. The median (range) gestational age at the time of delivery was 33.5 (30-40) weeks. There were nine vaginal deliveries and 15 operative deliveries. One patient had fetal loss at 19 weeks gestation. Twelve women had labour induced with an intravenous infusion of oxytocin at a rate of 0.001-0.02 IU·min(-1). An oxytocin infusion at a variable rate with a maximum dose of 0.05 IU·min(-1) was administered after vaginal delivery to maintain uterine tone. Epidural analgesia was initiated prior to induction of labour or in the latent phase of labour. Seven Cesarean deliveries were performed under combined spinal-epidural anesthesia, five were performed under epidural anesthesia, and three women had general anesthesia. Oxytocin was administered via an intravenous infusion at a rate of 0.05-0.2 IU·min(-1) after operative delivery. One patient had a cardiac arrest on induction of general anesthesia and was successfully resuscitated. There were no maternal or neonatal deaths. Ten women were followed up at our institution and at six months postpartum; 50% of these patients were still symptomatic.

CONCLUSION

We report favourable outcomes in 25 pregnant women with dilated cardiomyopathy who were managed by a multidisciplinary team.

Characteristics, adverse events, and racial differences among delivering mothers with peripartum cardiomyopathy

OBJECTIVES

The aim of this study was to identify clinical features associated with peripartum cardiomyopathy (PPCM) and possible racial differences and to quantify in-hospital outcomes in delivering mothers with PPCM.

BACKGROUND

Investigation of patient characteristics and outcomes in PPCM has been limited to small cohorts. Hospital discharge data allow assembly of the largest number of PPCM cases to date.

METHODS

Hospital records from 6 states were screened for PPCM. Clinical profiles, maternal, and fetal outcomes in delivering mothers with and without PPCM were compared and stratified by race. A maternal major adverse event (MAE) was defined as death, cardiac arrest, heart transplantation, or mechanical circulatory support. Logistic regression was used to identify variables associated with PPCM.

RESULTS

In total, 535 of 4,003,914 records of delivering mothers specified a diagnosis of PPCM. Prevalence of PPCM was highest among African Americans and similar in Caucasians and Hispanics. Established risk factors including age 30 years, African- American race, hypertension, preeclampsia/eclampsia, and multigestational status were associated with PPCM, and novel associations such as anemia and asthma were identified. Autoimmune disease and substance abuse, which can cause cardiomyopathy independently, were also associated with PPCM. Maternal MAE (odds ratio: 436, p < 0.0001) and stillbirth (odds ratio: 3.8, p < 0.0001) occurred more frequently among women with PPCM.

CONCLUSIONS

The prevalence of PPCM at the time of delivery in Hispanics was similar to Caucasians and lower than African Americans. Autoimmune disease, substance abuse, anemia and asthma were conditions associated with PPCM not consistently identified in smaller cohorts. Peripartum cardiomyopathy was also associated with increased risk of stillbirth and maternal MAEs at delivery.

Cardiomyopathies: Evolution of pathogenesis concepts and potential for new therapies

Cardiomyopathies are defined as diseases of the myocardium with associated structural and functional abnormalities. Knowledge of these pathologies for a long period was not clear in clinical practice due to uncertainties regarding definition, classification and clinical diagnosis. In recent decades, major advances have been made in the understanding of the molecular and genetic issues, pathophysiology, and clinical and radiological assessment of the diseases. Progress has been made also in management of several types of cardiomyopathy. Advances in the understanding of these diseases show that cardiomyopathies represent complex entities. Here, special attention is given to evolution of classification of cardiomyopathies, with the aim of assisting clinicians to look beyond schematic diagnostic labels in order to achieve more specific diagnosis. Knowledge of the genotype of cardiomyopathies has changed the pathophysiological understanding of their etiology and clinical course, and has become more important in clinical practice for diagnosis and prevention of cardiomyopathies. New approaches for clinical and prognostic assessment are provided based on contemporary molecular mechanisms of contribution in the pathogenesis of cardiomyopathies. The genotype-phenotype complex approach for assessment improves the clinical evaluation and management strategies of these pathologies. The review covers also the important role of imaging methods, particularly echocardiography, and cardiac magnetic resonance imaging in the evaluation of different types of cardiomyopathies. In summary, this review provides complex presentation of current state of cardiomyopathies from genetics to management aspects for cardiovascular specialists.

Epidemiology and natural history of recovery of left ventricular function in recent onset dilated cardiomyopathies

Although the long term prognosis of patients with dilated cardiomyopathy (DCM) remains poor, approximately 25 % of DCM patients with recent onset of heart failure (< 6 months) have a relatively benign clinical course with a spontaneously improvement in symptoms and partial, or in some cases complete, recovery of left ventricular (LV) function. Despite the longstanding recognition of the clinical phenomenon of LV recovery, relatively little attention has been paid to the etiology and natural history of this important group of DCM patients. Accordingly, in the present review we will focus on the epidemiology and natural history of recent onset DCM in patients who undergo spontaneous resolution of symptoms that is accompanied by recovery of LV function.

An update on treatments and outcomes in peripartum cardiomyopathy

ABSTRACT: 

Peripartum cardiomyopathy (PPCM) is a well-established complication of pregnancy. Criteria include heart failure that presents with reduced left ventricular function, signs and symptoms of heart failure either late in pregnancy or early in the postpartum period. The incidence varies widely depending geography and ethnicity. The pathophysiology of PPCM is still an area of active investigation, but includes immune and inflammatory mechanisms, which are the subject of several investigations. Therapies for chronic heart failure from PPCM are similar to those patients with nonischemic cardiomyopathy from different etiologies, however novel therapies may include bromocriptine, pentoxifylline or other potential therapies influencing the immune system. The need for implantable defibrillators, left ventricular assist devices and cardiac transplant in women with PPCM is rare, and prognosis is better than other forms of nonischemic cardiomyopathy. Despite this, further information about the epidemiology, prognosis and potential therapies are required to better manage and diagnose PPCM in women with signs and symptoms of heart failure.

Anesthetic experience using extracorporeal membrane oxygenation for cesarean section in the patient with peripartum cardiomyopathy: a case report

Peripartum cardiomyopathy is a rare form of cardiomyopathy that is associated with significant mortality. It can cause a cardiac arrest during cesarean section even though the patient does not have any previous symptom and sign. The most important thing of anesthesia in this patient is an optimization of hemodynamic and respiratory status. We report the successful general anesthesia using of extracorporeal membrane oxygenation for cesarean section in a 34-year-old woman with fulminant peripartum cardiomyopathy.

Peripartum cardiomyopathy: moving towards a more central role of genetics

Peripartum cardiomyopathy (PCM) is a relatively rare disease with potentially devasting consequences requiring prompt identification and correct treatment. Overall prognosis is good in majority of the cases, although some patients may progress to irreversible heart failure. Early diagnosis is important and effective treatment reduces mortality rates and increases the chance of complete recovery of ventricular systolic function. The aetiology and pathogenesis seems to be multifactorial and poorly understood, with the available literature rather conflicting. In recent years, there has been increased interest in the role played by genetic predisposition in the development of PCM. It probably develops as a result of a complex interaction of pregnancy-associated factors and genetic factors and recently there have been many observations pointing out the central role played by a genetic predisposition. The direct and indirect observations on genetic susceptibility may offer new insights into the pathogenesis of PCM. However, larger studies are needed before advising routine genetic testing in these patients.

[Peripartum cardiomyopathy: a rare, unknown and potentially fatal disease]

Peripartum cardiomyopathy occurs in women with no prior history of cardiac dysfunction, and is presented by left heart failure. It occurs late in pregnancy or in the months after delivery. Rare in Europe, it is not well-known by obstetricians. The prognosis can be good with restitutio in integrum of the maternal cardiac function but the outcome can be dramatic and lead to death of the patient as the case in this report.

Can peripartum cardiomyopathy be caused by chemotherapy and radiation of breast cancer?

Aim: To report on a pregnant woman with peripartum cardiomyopathy 7 years after combination chemotherapy with doxorubicine and radiation of cancer of the left breast.

Case: A 35-year old primigravida who was treated 7 years earlier with cancer of the left breast (ympT1c, ypN0, cM0), according to a neoadjuvant study protocol (GeparTrio), was transferred to our unit due to HELLP syndome at 35+5 weeks. Symptoms of cardiopulmonary decompensation occurred shortly after cesarean delivery of a healthy newborn. The patient was admitted to cardiac intensive care and treated with oxygen, diuretics and ACE inhibitors. Maternal left ventricular ejection fraction recovered within a few weeks without any surgical interventions and remained stable within 1 year of follow-up.

Conclusion: The association between radical primary treatment of the left breast and life-threatening cardiac disease could possibly be provoked by pregnancy.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare form of unexplained cardiac failure of unknown origin, unique to the pregnant woman with highly variable outcome associated with high morbidity and mortality. PPCM is fraught with controversies in its definition, epidemiology, pathophysiology, diagnosis and management. PPCM is frequently under diagnosed, inadequately treated and without a laid down follow-up regimen, thus, the aim of this review. Publications on PPCM were accessed using Medline, Google scholar and Pubmed databases. Relevant materials on PPCM, selected references from internet services, journals, textbooks, and lecture notes on PPCM were also accessed and critically reviewed. PPCM is multifactorial in origin. It is a diagnosis of exclusion and should be based on classic echocardiographic criteria. The outcome of PPCM is also highly variable with high morbidity and mortality rates. Future pregnancies are not recommended in women with persistent ventricular dysfunction because the heart cannot tolerate increased cardiovascular workload associated with the pregnancy. Although, multiparity is associated with PPCM, there is an increased risk of fetal prematurity and fetal loss. PPCM is a rare form of dilated cardiomyopathy of unknown origin, unique to pregnant women. The pathophysiology is poorly understood. Echocardiography is central to diagnosis of PPCM and effective treatment monitoring in patients of PPCM. The outcome is highly variable and related to reversal of ventricular dysfunction.

Gender disparity in cardiovascular disease: bias or biology?

This article addresses gender disparity in cardiovascular disease, with selected examples used to explore whether these disparities represent bias, biology or both. Gender-specific basic and clinical cardiovascular research is needed to address these issues, with rigorous application required for the emerging knowledge. These explorations offer promise to improve cardiovascular outcomes for women and are the basis for the application of gender-based evaluation of pathophysiology, clinical presentations, preventive interventions, diagnostic strategies, therapies and outcomes of cardiovascular disease in women.

Anesthetic management for caesarean section in a case of peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a disease of unknown etiology which affects pregnant females during late pregnancy or during the first 5 months post-partum. The clinical presentation of these patients is similar to that of patients with dilated cardiomyopathy. Anesthetic management of such cases poses a challenge; due to the increased risk of various perioperative complications. We report the successful anesthetic management of lower segment caesarean section in a patient with PPCM.

Could it be Quetiapine-induced Peripartum Cardiomyopathy?

Peri-partum Cardiomyopathy (PPCM) is a rare and life threatening complication of pregnancy. There are only two cases registered with the World Health Organization of cases of cardiomyopathy in patients taking Quetiapine. Here we discuss an interesting case of potential Quetiapine induced cardiomyopathy.