Burden of arrhythmias in peripartum cardiomyopathy: Analysis of 9841 hospitalizations

Catheter ablation in a monochorionic diamniotic twin pregnancy: A case report and literature review

RATIONALE

Preexcitation syndrome is an uncommon congenital cardiac disorder that impairs the normal cardiac conduction system. Radiofrequency ablation is one of the most effective treatments for this condition. Nevertheless, radiofrequency ablation is rare in women with preexcitation syndrome during pregnancy.

PATIENT CONCERNS

A 33-year-old woman with monochorionic diamniotic twin pregnancy complicated by sinus arrhythmia with ventricular preexcitation at 14 weeks and 5 days of gestation, with paroxysmal palpitations and shortness of breath at 16 weeks with paroxysmal supraventricular tachycardia with preexcitation syndrome and a heart rate ranging from 180 to 225 beats per minute.

DIAGNOSES

The pregnant occurred sudden palpitations and shortness of breath in the shower. Electrocardiography revealed paroxysmal supraventricular tachycardia, and electrophysiological study revealed preexcitation syndrome (dominant accessory route of the left free wall) with atrioventricular reentrant tachycardia.

INTERVENTIONS

Radiofrequency catheter ablation was performed at 20 weeks.

OUTCOMES

Symptoms of preexcitation syndrome resolved after the radiofrequency catheter ablation, and 2 healthy infants were delivered at 36 weeks and 2 days of gestation by cesarean section.

LESSONS

Preexcitation syndrome may result in life-threatening arrhythmias such as supraventricular tachycardia during pregnancy and delivery. It might be efficiently controlled through optimal treatment by a multidisciplinary team, which would effectively minimize arrhythmia risk events during pregnancy and improve maternal-fetal outcomes. Based on the patient's individual situation, radiofrequency ablation may be a procedure in pregnant women with preexcitation syndrome.

Living with peripartum cardiomyopathy: A statement from the Heart Failure Association and the Association of Cardiovascular Nursing and Allied Professions of the European Society of Cardiology

This statement focuses on the fact that women with peripartum cardiomyopathy (PPCM) have a substantial mortality and morbidity rate. Less than 50% of patients have full recovery of their cardiac function within 6 months of diagnosis. Also, patients with recovered cardiac function often suffer from comorbidities, such as hypertension or arrhythmias, which require long-term treatment. This has major implications which extend beyond the life of the patient, as it may also substantially impact her family. Women with a new diagnosis of PPCM should be involved in the decision-making processes regarding therapies, e.g. the recommendation to abstain from breastfeeding, or the use of cardiac implantable electronic devices. Women living with PPCM face the uncertainty of not knowing for some time whether their cardiac function will recover to allow them a near-to-normal life expectancy. This not only impacts their ability to work, which may have financial implications, but may also affect mental health and quality of life for the extended family. Women living with PPCM must be informed that a future pregnancy always carries a substantial risk and, in case of poor cardiac recovery, is associated with a high morbidity and mortality. Patients with PPCM are best managed by an interdisciplinary and multiprofessional approach including e.g. a cardiologist, a gynaecologist, nurses, a psychologist, and social workers. The scope of this document encompasses contemporary challenges and approaches for the management of women diagnosed with PPCM.

Atrial fibrillation considerations in the fourth trimester (postpartum period)

Postpartum atrial fibrillation is an uncommon but increasingly prevalent tachyarrhythmia that merits special management considerations with regards to the safety and efficacy of anticoagulation, rate and rhythm control as well as drug exposure to infants throughout breastfeeding. In this state-of-the-art review, we examine the demographics of postpartum atrial fibrillation with its associated risk factors, describe the safety of commonly used atrial fibrillation therapies, and discuss important considerations for women considering subsequent pregnancies.

Cardiomyopathies in Women

Heart failure affects over 2.6 million people in the United States. While women have better overall survival rates, they also suffer from higher morbidity as shown by higher rates of hospitalization and worse quality of life. Several anatomical differences in women's hearts affect both systolic and diastolic cardiac physiology. Despite these findings, women are significantly underrepresented in clinical trials, necessitating extrapolation of data from males. Because women have sex-specific etiologies of heart failure and unique manifestations in genetic-related cardiomyopathies, meaningful sex-related differences affect heart failure outcomes as well as access to and outcomes in advanced heart failure therapies in women. This review explores these gender-specific differences and potential solutions to balance care between women and men.

Ventricular Tachycardia in Patients With Peripartum Cardiomyopathy: Prevalence, Predictors, and Associated In-Hospital Adverse Events

Introduction  The purpose of this study was to determine the prevalence of ventricular tachycardia (VT) among patients admitted with peripartum cardiomyopathy (PPCM) as well as to analyze the independent association of VT with in-hospital outcomes among PPCM patients. Methods Data were obtained from the National Inpatient Sample from January 2016 to December 2019. We assessed predictors of VT in patients admitted with PPCM. We also assessed the independent association of VT with clinical outcomes among patients admitted with PPCM. Results From 2016 to 2019, 4730 patients with PPCM were reported to the national inpatient sample database, 309 of which developed VT (6.5%). Using multivariate analysis, we found predictors of VT to include patient characteristics and factors such as age (adjusted OR (aOR)=1.020, p=0.023), chronic kidney disease (aOR=1.440, p=0.048), coagulopathy (aOR=1.964, p=0.006), and atrial fibrillation (aOR=3.965, p<0.001). Conversely, pre-eclampsia was significantly associated with a decreased risk of VT in PPCM patients (aOR=0.218, p=0.001).  Conclusion  In a large cohort of patients admitted with peripartum cardiomyopathy, we found the prevalence of VT to be 6.5%. Risk factors for VT in this patient population included conditions such as coagulopathy and atrial fibrillation.

Peripartum Cardiomyopathy: Current Understanding of Pathophysiology, Diagnostic Workup, Management, and Outcomes

Peripartum cardiomyopathy (PPCM) is a relatively rare, potentially life-threatening, idiopathic form of cardiomyopathy that affects previously healthy young women during late pregnancy or in the early postpartum period and is characterized by left ventricular (LV) systolic dysfunction in the absence of any other identifiable cardiac causes. Morbidity and mortality with PPCM are remarkably high and it continues to be one of the leading causes of maternal death. Although remarkable advances have been made in our understanding of PPCM in the last few decades, unanswered questions remain regarding its pathophysiology, diagnostic workup, and management options. In this article, we will complete an updated, comprehensive review of PPCM, including the epidemiology and risk factors, proposed etiology, presentation and complications, management, prognostic indicators and outcomes. In addition, we will identify current challenges and gaps in knowledge.

Peripartum cardiomyopathy: risk factors and predictors of outcome

PURPOSE OF REVIEW

Peripartum cardiomyopathy (PPCM) contributes significantly to maternal morbidity and mortality worldwide. In this review, we describe the present-day epidemiology and current understanding of the pathogenesis of PPCM. We provide an updated approach to diagnosis and management of PPCM, and discuss risk factors and predictors of outcome.

RECENT FINDINGS

The highest incidences of PPCM have been reported in African, Asian, and Caribbean populations. Contemporary literature supports a 'two-hit' hypothesis, whereby the 'first hit' implies a predisposition, and the 'second hit' refers to an imbalanced peripartal hormonal milieu that results in cardiomyopathy. Whereas a half of patients will have left ventricular (LV) recovery, a tenth do not survive. Clinical findings and special investigations (ECG, echocardiography, cardiac MRI, biomarkers) can be used for risk stratification. Frequent prescription of guideline-directed medical therapy is associated with improved outcomes.

SUMMARY

Despite advances in elucidating the pathogenesis of PPCM, it remains unclear why only certain women develop the disease. Moreover, even with better diagnostic work-up and management, it remains unknown why some patients with PPCM have persistent LV dysfunction or die. Future research should be aimed at better understanding of the mechanisms of disease and finding new therapies that could improve survival and LV recovery.

Effectiveness of implantable loop recorder and Holter electrocardiographic monitoring for the detection of arrhythmias in patients with peripartum cardiomyopathy

BACKGROUND

Patients with peripartum cardiomyopathy (PPCM) are at increased risk of sudden cardiac death (SCD). However, the exact underlying mechanisms of SCD in PPCM remain unknown. By means of extended electrocardiographic monitoring, we aimed to systematically characterize the burden of arrhythmias occurring in patients with newly diagnosed PPCM.

METHODS AND RESULTS

Twenty-five consecutive women with PPCM were included in this single-centre, prospective clinical trial and randomised to receiving either 24 h-Holter ECG monitoring followed by implantable loop recorder implantation (ILR; REVEAL XT, Medtronic^®) or 24 h-Holter ECG monitoring alone. ILR + 24 h-Holter monitoring had a higher yield of arrhythmic events compared to 24 h-Holter monitoring alone (40% vs 6.7%, p = 0.041). Non-sustained ventricular tachycardia (NSVT) occurred in four patients (16%, in three patients detected by 24 h-Holter, and multiple episodes detected by ILR in one patient). One patient deceased from third-degree AV block with an escape rhythm that failed. All arrhythmic events occurred in patients with a severely impaired LV systolic function.

CONCLUSIONS

We found a high prevalence of potentially life-threatening arrhythmic events in patients with newly diagnosed PPCM. These included both brady- and tachyarrhythmias. Our results highlight the importance of extended electrocardiographic monitoring, especially in those with severely impaired LV systolic function. In this regard, ILR in addition to 24 h-Holter monitoring had a higher yield of VAs as compared to 24 h-Holter monitoring alone. In settings where WCDs are not readily available, ILR monitoring should be considered in patients with severely impaired LV systolic dysfunction, especially after uneventful 24 h-Holter monitoring.

TRIAL REGISTRATION

Pan African Clinical Trials Registry: PACTR202104866174807. Extended electrocardiographic monitoring for the detection of arrhythmias in PPCM. (CHB, complete heart block/third degree AV block; ECG, electrocardiogram; ILR, implantable loop recorder; NSVT, non-sustained ventricular tachycardia; PPCM, peripartum cardiomyopathy).

Impact of Atrial Fibrillation on In-hospital Outcomes and Healthcare Resource Utilization of Women With Peripartum Cardiomyopathy: A Study From National Inpatient Sample

There is limited data on the impact of atrial fibrillation (Afib) on hospital outcomes in females with peripartum cardiomyopathy (PPCM). The National Inpatient Sample (NIS) 2011-2019 was used to find patients with PPCM. PPCM patients were divided into two groups: with and without Afib. Baseline characteristics were compared between both groups. Logistic regression was used to find independent predictors of Afib. Out of 13,840 PPCM patients, 249 (1.8%) also had a diagnosis of Afib. The Afib group was older and had a high burden of comorbidities. PPCM patients with Afib had higher in-hospital mortality (4-vs-0.7%, p=0.02), mean length of stay (11.3-vs-4.3 days, p<0.001) and healthcare resource utilization. Old age, low-income quartile, liver disease, obstructive sleep apnea and acute posthemorrhagic anemia were significant predictors of Afib. In conclusion, Afib is associated with higher in-hospital mortality and worse outcomes in females with PPCM. Further research is needed to improve these outcomes.

Outcome of life-threatening arrhythmias among patients presenting in an emergency setting at a tertiary hospital in Accra-Ghana

Background

Management of life-threatening arrhythmia can be incredibly challenging in advanced health systems. In sub-Saharan Africa (SSA), this is likely more challenging because of weak pre-hospital and in-hospital critical care systems. Little is known about life-threatening arrhythmia and their outcomes in SSA. The aim of this study was to examine the types and outcomes of arrhythmias among haemodynamically unstable patients presenting at a tertiary hospital in Accra-Ghana.

Method

This was a retrospective case series study conducted at the Korle-Bu Teaching Hospital (KBTH), Accra-Ghana. Medical records of patients who presented with or developed haemodynamically unstable arrhythmias within 24h of admission from January 2018 to December 2020 were reviewed. The demographic characteristics and clinical data including outcomes of patients were collected. Descriptive statistics were used and results presented in frequency tables.

Results

A total of 42 patients with life-threatening arrhythmias were included. Haemodynamically unstable tachyarrhythmias were the most common arrhythmias found among the patients (66.7%). Approximately 52% of patients had structural heart diseases whereas 26.2% had no apparent underlying cause or predisposing factor. Cardioversion (52.4%), commonly electrical (63.6%), and transvenous pacemaker implantation (23.8%) were the common initial interventions. The majority of the patients (88.1%) survived and were discharged home.

Conclusion

Tachyarrhythmias are the most common haemodynamically unstable arrhythmias seen among patients presenting emergently in a leading tertiary hospital in Ghana. A high survival rate was observed and cannot be extrapolated to other healthcare settings in sub-Saharan Africa with limited resources to manage these clinical entities.

Wolff-Parkinson-White Syndrome and Peripartum Cardiomyopathy

Wolff-Parkinson-White (WPW) is a rare congenital arrhythmia that could result in peripartum cardiomyopathy. This condition could be managed by medical treatments or ablation treatments. In this report, we presented a 14-year-old pregnant girl with initial signs of syncope and palpitation, who was later diagnosed with WPW-induced peripartum cardiomyopathy. The baby was successfully delivered at 32 weeks gestational age, and the patient received a beta-blocker as the main treatment strategy. We recommend that a proper cardiology and gynecology care is critical in providing the best prognosis.

Peripartum Cardiomyopathy Presenting With Incessant Ventricular Arrhythmias

Sudden cardiac death is hypothesized to be one of the leading causes of mortality in peripartum cardiomyopathy. This case illustrates a patient who presented with cardiac arrest, and it discusses the importance of considering multiple causes of fulminant ventricular arrhythmias in the setting of decreased left ventricular function during the peripartum period. (Level of Difficulty: Advanced.)

Racial and Ethnic Disparities in the Trends and Outcomes of Cardiogenic Shock Complicating Peripartum Cardiomyopathy

IMPORTANCE

Cardiogenic shock (CS) is a recognized complication of peripartum cardiomyopathy (PPCM) associated with poor prognosis. Although racial and ethnic disparities have been described in the occurrence and outcomes of PPCM, it is unclear if these disparities persist among patients with PPCM and CS.

OBJECTIVES

To evaluate the temporal trends in CS incidence among hospitalized patients with PPCM stratified by race and ethnicity and to investigate the racial and ethnic differences in hospital mortality, mechanical circulatory support (MCS) use, and heart transplantation (HT).

DESIGN, SETTING, AND PARTICIPANTS

This multicenter retrospective cohort study included hospitalized patients with PPCM complicated by CS in the US from 2005 to 2019 identified from the National Inpatient Sample (NIS). Data analysis was conducted in November 2021.

EXPOSURE

PPCM complicated by CS.

MAIN OUTCOMES AND MEASURES

The main outcome was incidence of CS in PPCM stratified by race and ethnicity. The secondary outcome was racial and ethnic differences in hospital mortality, MCS use, and HT.

RESULTS

Of 55 804 hospitalized patients with PPCM, 1945 patients had CS, including 947 Black patients, 236 Hispanic patients, and 702 White patients, translating to an incidence rate of 35 CS events per 1000 patients with PPCM. The mean (SD) age was 31 (9) years. Black and Hispanic patients had higher CS incidence rates (39 events per 1000 patients with PPCM) compared with White patients (33 events per 1000 patients with PPCM). CS incidence rates significantly increased across all races and ethnicities over the study period. Overall, the odds of developing CS were higher in Black patients (aOR, 1.17 [95% CI, 1.15-1.57]; P < .001) and Hispanic patients (aOR, 1.37 [95% CI, 1.17-1.59]; P < 001) compared with White patients during the study period. Compared with White patients, the odds of in-hospital mortality were higher in Black (adjusted odds ratio [aOR], 1.67 [95% CI, 1.21-2.32]; P = .002) and Hispanic (aOR, 2.20 [95% CI, 1.45-3.33]; P < .001) patients. Hispanic patients were more likely to receive any type of MCS device (aOR, 2.23 [95% CI, 1.60-3.09]; P < .001), intraaortic balloon pump (aOR, 1.65 [95% CI, 1.11-2.44]; P < .001), and ventricular assisted device (aOR, 4.45 [95% CI, 2.45-8.08]; P < .001), compared with White patients. Black patients were more likely to receive VAD (aOR, 2.69 [95% CI, 1.63-4.42]; P < .001) compared with White patients. Black and Hispanic patients were significantly less likely to receive HT compared with White patients (Black patients: aOR, 0.51 [95% CI, 0.33-0.78]; P = .02; Hispanic patients: aOR, 0.15 [95% CI, 0.06-0.42]; P < .001).

CONCLUSIONS AND RELEVANCE

These findings highlight significant racial disparities in mortality and HT among hospitalized patients with PPCM complicated by CS in the US. More research to identify factors of racial and ethnic disparities is needed to guide interventions to improve outcomes of patients with PPCM.

Arrhythmias and Heart Failure in Pregnancy: A Dialogue on Multidisciplinary Collaboration

The prevalence of CVD in pregnant people is estimated to be around 1 to 4%, and it is imperative that clinicians that care for obstetric patients can promptly and accurately diagnose and manage common cardiovascular conditions as well as understand when to promptly refer to a high-risk obstetrics team for a multidisciplinary approach for managing more complex patients. In pregnant patients with CVD, arrhythmias and heart failure (HF) are the most common complications that arise. The difficulty in the management of these patients arises from variable degrees of severity of both arrhythmia and heart failure presentation. For example, arrhythmia-based complications in pregnancy can range from isolated premature ventricular contractions to life-threatening arrhythmias such as sustained ventricular tachycardia. HF also has variable manifestations in pregnant patients ranging from mild left ventricular impairment to patients with advanced heart failure with acute decompensated HF. In high-risk patients, a collaboration between the general obstetrics, maternal-fetal medicine, and cardiovascular teams (which may include cardio-obstetrics, electrophysiology, adult congenital, or advanced HF)—physicians, nurses and allied professionals—can provide the multidisciplinary approach necessary to properly risk-stratify these women and provide appropriate management to improve outcomes.

Peripartum cardiomyopathy: a review of current literature

Peripartum cardiomyopathy (PPCM) is systolic heart failure in a woman who is pregnant or in the early postpartum period. There are multiple theories regarding the pathophysiology of this disease, and it is suspected the true cause is a combination of these theories. Presenting symptoms are similar to that of systolic heart failure from other causes and must be carefully differentiated from normal changes that occur during pregnancy. PPCM may progress to chronic heart failure and result in various complications if not treated early. This paper offers a comprehensive review of currently accepted pathophysiologic theories, major signs and symptoms, possible complications and treatments of PPCM.

Management of Wolff-Parkinson-White syndrome in a patient with peripartum cardiomyopathy

Wolf-Parkinson-White (WPW) syndrome is a congenital heart condition in which the atrioventricular (AV) node is bypassed by an accessory pathway that connects the atria and ventricle directly along with symptoms of syncope or palpitations. WPW syndrome in patients with a history of peripartum cardiomyopathy (pregnancy-related cardiomyopathy) is associated with a high risk of morbidity and mortality secondary to failure of the pump and the conduction system of the heart. Management of these cases deals with arrhythmia and systolic heart failure, which becomes more challenging in pregnant patients as it requires treatment methods that minimize risks to the fetus. We report a case of a young female patient with WPW syndrome and peripartum cardiomyopathy presenting with symptomatic arrhythmias (tachycardia).

[Peripartum cardiomyopathy: A review of the literature]

Peripartum cardiomyopathy is a rare and unpredictable pregnancy-related pathology. Idiopathic cardiomyopathy is characterized by a heart failure secondary to left ventricular systolic dysfunction appearing towards the end of pregnancy or in the months following delivery with a non-specific clinic presentation. Through reviewing previous research, our critical literature review wishes to bring a concise and objective summarize for a better understanding of physiopathology, evocative symptoms and knowing of factors influencing prognosis in order to standardize peripartum management. The treatment remains mainly symptomatic but other promising treatments are still in development. In conclusion, early detection and treatment allow a better cardiac function recovery reducing cardiac transplantation.

Peripartum Cardiomyopathy

Importance

Peripartum cardiomyopathy is a rare form of heart failure due to left ventricular systolic dysfunction that affects women late in pregnancy and the postpartum period. A diagnosis of exclusion, peripartum cardiomyopathy can be difficult to diagnose in the context of the normal physiologic changes of pregnancy and requires a high index of suspicion.

Evidence Acquisition

Original research articles, review articles, and guidelines on peripartum cardiomyopathy were reviewed.

Results

The etiology of peripartum cardiomyopathy remains poorly defined, but theories include genetic predisposition, as well as myocardial inflammation and angiogenic dysregulation. Risk factors for this condition include hypertensive disorders of pregnancy, Black race, and maternal age older than 30 years. Patients with peripartum cardiomyopathy are at increased risk of acute clinical decompensation, cardiac arrhythmias, thromboembolic complications, and death. Primary treatment modalities include initiation of a medication regimen aimed at the optimization of preload and reduction of afterload. Maternal clinical status is the primary determinant for timing of delivery.

Conclusions

Prompt diagnosis and medical management by an interdisciplinary care team are vital for improving outcomes in patients with peripartum cardiomyopathy.

Cardiomyopathies: An Overview

Background: Cardiomyopathies are a heterogeneous group of pathologies characterized by structural and functional alterations of the heart. Aims: The purpose of this narrative review is to focus on the most important cardiomyopathies and their epidemiology, diagnosis, and management. Methods: Clinical trials were identified by Pubmed until 30 March 2021. The search keywords were “cardiomyopathies, sudden cardiac arrest, dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), restrictive cardiomyopathy, arrhythmogenic cardiomyopathy (ARCV), takotsubo syndrome”. Results: Hypertrophic cardiomyopathy (HCM) is the most common primary cardiomyopathy, with a prevalence of 1:500 persons. Dilated cardiomyopathy (DCM) has a prevalence of 1:2500 and is the leading indication for heart transplantation. Restrictive cardiomyopathy (RCM) is the least common of the major cardiomyopathies, representing 2% to 5% of cases. Arrhythmogenic cardiomyopathy (ARCV) is a pathology characterized by the substitution of the myocardium by fibrofatty tissue. Takotsubo cardiomyopathy is defined as an abrupt onset of left ventricular dysfunction in response to severe emotional or physiologic stress. Conclusion: In particular, it has been reported that HCM is the most important cause of sudden death on the athletic field in the United States. It is needless to say how important it is to know which changes in the heart due to physical activity are normal, and when they are pathological.

ECG and arrhythmias in peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare but life-threatening heart disease, with onset in the last month of pregnancy or in the first months after delivery. Extensive studies on the burden of supraventricular and ventricular arrhythmias are lacking. Patients with PPCM present with electrocardiographic findings typical in acute heart failure. Management of arrhythmias in PPCM depends on the severity and the onset (during pregnancy or after delivery). Studies on the use of the wearable cardioverter-defibrillator in patients with PPCM show a substantial burden of ventricular tachyarrhythmias and sudden death in patients with severely reduced left ventricular function. The aim of the present article is to summarize actual knowledge on electrocardiogram findings, arrhythmias, and sudden cardiac death in patients with PPCM.

Peripartum cardiomyopathy

Peripartum cardiomyopathy is now increasingly recognized as a cause of heart failure in the later months of pregnancy and early postpartum period. Clinical diagnosis may be challenging as it closely resembles several common medical and obstetric complications. Complex pathogenesis, unpredictable onset, staggered recovery, and unanticipated fetomaternal risks pose unique challenge to clinicians. Prevalence seems to vary with race, geographic location, and diagnostic criteria. The presence of multiple risk factors substantially elevates the risk of PPCM. Transthoracic echocardiographic examination can exclude the majority of the mimickers. Symptomatic presentation is initially limited to, varying grades of low cardiac output syndrome. Rarely, PPCM begins with decompensated heart failure and cardiovascular collapse. Guideline-directed medical therapy involves graded initiation and titration of heart failure medications while ensuring the fetal and neonatal safety. Anesthetic and obstetric management should be individualized to improve fetomaternal outcomes. However, emergent cesarean delivery may be required in women with decompensated heart failure and cardiovascular collapse. An early institution of mechanical circulatory support has shown to improve outcome. Bromocriptine and other experimental drugs designed to target pathogenic pathway have yielded mixed results. A further change in approach to management requires a comprehensive understanding of pathophysiology and fetomaternal safety profiles of heart failure medications.

Management of tachyarrhythmias in pregnancy - A review

The most common arrhythmias detected during pregnancy include sinus tachycardia, sinus bradycardia, and sinus arrhythmia, identified in 0.1% of pregnancies. Isolated premature atrial or ventricular arrhythmias are observed in 0.03% of pregnancies. Arrhythmias may become more frequent during pregnancy or may manifest for the first time.

Cardiac arrhythmias in pregnant women: need for mother and offspring protection

Cardiac arrhythmias are the most common cardiac complication reported in pregnant women with and without structural heart disease (SHD); they are more frequent among women with SHD, such as cardiomyopathy and congenital heart disease (CHD). While older studies had indicated supraventricular tachycardia as the most common tachyarrhythmia in pregnancy, more recent data indicate an increase in the frequency of arrhythmias, with atrial fibrillation (AF) emerging as the most frequent arrhythmia in pregnancy, attributed to an increase in maternal age, cardiovascular risk factors and CHD in pregnancy. Importantly, the presence of any tachyarrhythmia during pregnancy may be associated with adverse maternal and fetal outcomes, including death. Thus, both the mother and the offspring need to be protected from such consequences. The use of antiarrhythmic drugs (AADs) depends on clinical presentation and on the presence of underlying SHD, which requires caution as it promotes pro-arrhythmia. In hemodynamically compromised women, electrical cardioversion is successful and safe to both mother and fetus. Use of beta-blockers appears quite safe; however, caution is advised when using other AADs, while no AAD should be used, if at all possible, during the first trimester when organogenesis takes place. Regarding the anticoagulation regimen in patients with AF, warfarin should be substituted with heparin during the first trimester, while direct oral anticoagulants are not indicated given the lack of data in pregnancy. Finally, for refractory arrhythmias, ablation and/or device implantation can be performed with current techniques in pregnant women, when needed, using minimal exposure to radiation. All these issues and relevant current guidelines are herein reviewed.

Detection and management of arrhythmias in peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is an idiopathic dilated cardiomyopathy, in which previously healthy women present with heart failure secondary to left ventricular (LV) systolic dysfunction during the last months of pregnancy or up to 5 months postpartum. PPCM occurs worldwide. The incidence seems to be increasing, possibly due to increasing awareness of the condition and diagnosis thereof. Women diagnosed with PPCM present with symptoms and signs of heart failure, thromboembolism or arrhythmia. Although the incidence of arrhythmias in this condition is not well documented, patients with PPCM often have rhythm disturbances. Indeed, life-threating arrhythmias contribute significantly to sudden cardiac death (SCD) in this population, especially when patients have poor systolic function. In this review, we summarize the evidence on atrial and ventricular arrhythmias in PPCM, as detected by various diagnostic modalities. Furthermore, we summarize the management of arrhythmias in PPCM, as recommended by contemporary guidelines.

Predictors, burden and impact of cardiac arrhythmias among patients hospitalized with end-stage liver disease

BACKGROUND

Cirrhotic cardiomyopathy, hyperammonemia, and hepatorenal syndrome predispose to cardiac arrhythmias in End-stage liver disease (ESLD).

OBJECTIVES

Among ESLD hospitalizations, we evaluate the distribution and predictors of arrhythmias and their impact on hospitalization outcomes.

METHODS

We selected ESLD records from the Nationwide Inpatient Sample (2007-2014), identified concomitant arrhythmias (tachyarrhythmias and bradyarrhythmias), and their demographic and comorbid characteristics, and estimated the effect of arrhythmia on outcomes (SAS 9.4).

RESULTS

Of 57,119 ESLD hospitalizations, 6,615 had arrhythmias with higher odds with increasing age, males, jaundice, hepatorenal syndrome, alcohol use, and cardiopulmonary disorders. The most common arrhythmias were atrial fibrillation, cardiac arrest/asystole, and ventricular tachycardia. After propensity-matching (arrhythmia: no-arrhythmia, 6,609:6,609), arrhythmias were associated with 200% higher mortality, 1.7-days longer stay, $32,880 higher cost, and higher rates of shock, respiratory and kidney failures.

CONCLUSIONS

Due to worse outcomes with arrhythmias, there is a need for better screening and follow-up of ESLD patients for dysrhythmias.

Life-threatening peripartum cardiomyopathy-Not expected when expecting

Peripartum cardiomyopathy is challenging to diagnose as it mimics symptoms present in normal pregnancy. The clinical course and prognosis are various. In selected cases, a cardioverter implantable defibrillator with/without cardiac resynchronization therapy, mechanical ventricular assist device treatment, and transplantation is indicated.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare, often dilated, cardiomyopathy with systolic dysfunction that presents in late pregnancy or, more commonly, the early postpartum period. Although the condition is prevalent worldwide, women with black ancestry seem to be at greatest risk, and the condition has a particularly high incidence in Nigeria and Haiti. Other risk factors include pre-eclampsia, advanced maternal age, and multiple gestation pregnancy. Although the complete pathophysiology of peripartum cardiomyopathy remains unclear, research over the past decade suggests the importance of vasculo-hormonal pathways in women with underlying susceptibility. At least some women with the condition harbor an underlying sarcomere gene mutation. More than half of affected women recover systolic function, although some are left with a chronic cardiomyopathy, and a minority requires mechanical support or cardiac transplantation (or both). Other potential complications include thromboembolism and arrhythmia. Currently, management entails standard treatments for heart failure with reduced ejection fraction, with attention to minimizing potential adverse effects on the fetus in women who are still pregnant. Bromocriptine is one potential disease specific treatment under investigation. In this review, we summarize the current literature on peripartum cardiomyopathy, as well as gaps in the understanding of this condition and future research directions.

Predictors, Burden, and the Impact of Arrhythmia on Patients Admitted for Acute Myocarditis

A significant proportion of patients with acute myocarditis experience sudden cardiac death presumably due to cardiac arrhythmia. In this study, we explore the burden, the predictors of arrhythmia in acute myocarditis and the association between arrhythmias and adverse in-hospital outcomes. After evaluating the frequency of various tachyarrhythmias and bradyarrhythmia in myocarditis population, we built a logistic model to determine the independent predictors of arrhythmias in myocarditis and a 1:1 propensity-matched analysis to examine the impact of arrhythmias. Overall, cardiac arrhythmias were identified in 33.71% of the hospitalized myocarditis cases. Ventricular tachycardia and atrial fibrillation were most common arrhythmias. There were increased odds of in-hospital mortality, cardiogenic shock, use of mechanical circulatory support, pacemaker implantation, and nonroutine hospital discharges in the arrhythmia cohorts. Length of stay and cost of hospitalization were also significantly higher. A significant proportion of patients with myocarditis have cardiac arrhythmias. As the occurrence of arrhythmias in myocarditis is associated with worse outcomes, it may be important to risk stratify patient to identify those who will benefit from early intervention.

The prognostic significance of the 12-lead ECG in peripartum cardiomyopathy

BACKGROUND

Peripartum cardiomyopathy (PPCM) is an important cause of pregnancy-associated heart failure, which appears in previously healthy women towards the end of pregnancy or within five months following delivery. Although the ECG is widely used in clinical practice, its prognostic value has not been established in PPCM.

METHODS

We analysed 12-lead ECGs of patients with PPCM, taken at index presentation and follow-up visits at 6 and 12 months. Poor outcome was determined by the composite endpoint of death, readmission, NYHA functional class III/IV or left ventricular ejection fraction (LVEF) of ≤35% at follow-up.

RESULTS

This cohort of 66 patients had a median age of 28.59 (IQR 25.43-32.19). The median LVEF at presentation (33%, IQR 25-40) improved significantly at follow-up (LVEF 49%, IQR 38-55, P < 0.001 at 6 months; 52% IQR 38-57, P = 0.001 at 12 months). Poor outcome occurred in 27.91% at 6 months and 41.18% at 1 year. Whereas sinus tachycardia at baseline was an independent predictor of poor outcome at 12 months (OR 6.56, 95% CI 1.17-20.41, P = 0.030), sinus arrhythmia was associated with event free survival (log rank P = 0.013). T wave inversion was associated with an LVEF ≤35% at presentation (P = 0.038), but did not predict poor outcome. A prolonged QTc interval at presentation (found in almost half of the cohort) was an independent predictor of poor outcome at 6 months (OR 6.34, 95% CI 1.06-37.80, P = 0.043).

CONCLUSION(S)

A prolonged QTc and sinus tachycardia at baseline were independent predictors of poor outcome in PPCM at 6 months and 1 year respectively.

Peripartum Cardiomyopathy: a Review for the Clinician

PURPOSE OF REVIEW

This review summarizes the pathophysiology, diagnosis, and treatment of peripartum cardiomyopathy (PPCM), with a focus on recent discoveries of clinical relevance.

RECENT FINDINGS

An increase in oxidative stress and anti-angiogenic activity play key roles in the pathophysiology of peripartum cardiomyopathy. Therapies that target this dysregulation may have a future role in treatment. Suppression of prolactin release using bromocriptine, a dopamine-receptor antagonist, has been associated with more favorable outcomes in small studies but more research is needed. Similarly, VEGF agonists may prove to be a novel therapy by upregulating angiogenesis. Peripartum cardimyopathy typically presents in the third trimester or in first few months postpartum. Both genetic and clinical risk factors for PPCM have been identified. Women with PPCM should be managed by a multidisciplinary team with experience in high risk pregnancy and the treatment of heart failure. These women benefit from the use of standard treatments for heart failure therapy with the exception of avoiding ACE inhibitors and ARBs while pregnant. While the rate of recovery of ventricular function in PPCM is higher than in other forms of dilated cardiomyopathy, mechanical circulatory support and/or cardiac transplantation are required in some cases.

Arrhythmic manifestation of peripartum cardiomyopathy-Case report

We report a case of 26-year-old woman, with arrhythmic manifestation of peripartum cardiomyopathy with moderate heart failure. Ventricular arrhythmia recorded in ambulatory Holter ECG (premature ventricular contractions) was most severe during pregnancy, reduced when beta-blocker therapy was initiated and almost completely resolved after delivery. Then, 1 year after hospitalization in Cardiology Department, recurrence was observed with recorded short episode of nonsustained ventricular tachycardia.