Heart transplantation for peripartum cardiomyopathy

Interventions for treating peripartum cardiomyopathy to improve outcomes for women and babies

BACKGROUND

Peripartum cardiomyopathy (PPCM or PCMO) is a rare disease of unknown etiology, characterised by an acute onset of heart failure in women in the late stage of pregnancy or in the early months postpartum.

OBJECTIVES

To assess the effectiveness and safety of any intervention for the care of women and/or their babies with a diagnosis of peripartum cardiomyopathy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 July 2010) and the reference lists of identified studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of any intervention for treating peripartum cardiomyopathy. Such interventions include: drugs; cardiac monitoring and treatment; haemodynamic monitoring and treatments; supportive therapies and heart transplant.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked.

MAIN RESULTS

We identified and included one pilot study, involving 20 women, undertaken in South Africa. Women were diagnosed postnatally and included in the study within 24 hours of diagnosis.

AUTHORS' CONCLUSIONS

There are insufficient data to draw any firm conclusions. Treatment with bromocriptine appears promising, although women would be unable to breastfeed due to suppression of lactation.

Peripartum cardiomyopathy: review of the literature

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

Peripartum cardiomyopathy: a comprehensive review

Peripartum cardiomyopathy (PPCM) is a rare disorder in which left ventricular dysfunction and symptoms of heart failure occur in the peripartum period in previously healthy women. Incidence of PPCM ranges from 1 in 1300 to 1 in 15,000 pregnancies. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The diagnostic criteria are onset of heart failure in the last month of pregnancy or in first 5 months postpartum, absence of determinable cause for cardiac failure, and absence of a demonstrable heart disease before the last month of pregnancy. Risk factors for PPCM include advanced maternal age, multiparity, African race, twinning, gestational hypertension, and long-term tocolysis. The clinical presentation of patients with PPCM is similar to that of patients with dilated cardiomyopathy. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Treatment is similar to medical therapy for other forms of dilated cardiomyopathy. About half the patients of PPCM recover without complications. The prognosis is poor in patients with persistent cardiomyopathy. Persistence of disease after 6 months indicates irreversible cardiomyopathy and portends worse survival.

Severe cardiac disease in pregnancy, part II: impact of congenital and acquired cardiac diseases during pregnancy

PURPOSE OF REVIEW

Part II of this review gives an overview of the different maternal cardiac problems during pregnancy and their management, and developments over recent years.

RECENT FINDINGS

Many studies published over the last 5 years provided new insights on different cardiac diseases in pregnancy. Publications discussed in this part of the review on cardiac disease in pregnancy, for example, provide epidemiological data on heart disease during pregnancy in general, and cardiomyopathy and ischemic heart disease in particular. In addition, we discussed the implications of a history of peripartum cardiomyopathy for a subsequent pregnancy, interventional strategies during pregnancy in women with ischemic heart disease, and the role of echocardiography in the evaluation of cardiac disease in pregnancy.

SUMMARY

The prevalence of the different causes of heart disease has shifted towards congenital heart disease by the end of the millennium. In developing countries, relatively rare diseases like rheumatic fever are still common, so these diseases are increasingly 'exported' to developed countries. The group of women with congenital heart disease represents most women with heart disease during pregnancy, followed by rheumatic heart disease. With the exception of patients with Eisenmenger's syndrome, pulmonary vascular obstructive disease, and Marfan's syndrome with aortopathy, maternal death during pregnancy is rare in women with heart disease. Although the risk for mortality is low in pregnant women with preexistent cardiac disease, these women are at increased risk for serious morbidity such as heart failure, arrhythmias, and stroke.

Peripartum cardiomyopathy: a condition intensivists should be aware of

We use an illustrative case of severe peripartum cardiomyopathy with congestive heart failure to introduce this topic and proceed to cover its pathophysiology, incidence, management and outcome.

[Peripartum dilated cardiomyopathies: is there a correlation with sexually transmitted diseases?]

A revue of litérature about peripartum cardiomyopathy; a disease of unknown pathogenesis. Some retrospective studies suggest a relation with sexually transmitted diseases. Other risk factors were observed. Diuretics and digoxin are used in the treatment. Cardiac transplantation is the final solution but the affection could appear again. A database must be started with epidemiologic information to understand this disorder and its correlation with sexually transmitted diseases.

Heart transplantation for peripartum cardiomyopathy: a report of three cases and a literature review

Peripartum cardiomyopathy is a devastating medical condition and carries a mortality of up to 60% with medical treatment. The authors describe their experience of successful outcome of three cases with heart transplantation and review the literature. The importance of performance of endomyocardial biopsy for all peripartum cardiomyopathy patients is emphasized. It is recommended that heart transplantation should only be offered to myocarditis negative patients.

Novacor LVAD bridge to transplantation in peripartum cardiomyopathy

We report the case of a 22-year-old woman suffering from peripartum cardiomyopathy who was successfully bridged to cardiac transplantation with a Novacor left ventricular assist device (LVAD). Her course with the device is presented and emphasis is put on the size mismatch between the patient and the device, a fact with normally precludes the implantation of the Novacor LVAD.

Long-term outcome after heart transplantation for peripartum cardiomyopathy

To elucidate the long-term outcome and frequency of complications after heart transplantation for peripartum cardiomyopathy (PPCM), we compared the courses of eight consecutive patients undergoing transplantation for PPCM with those of nine female age-matched control subjects undergoing transplantation for idiopathic dilated cardiomyopathy (IDCM). No significant differences could be found in baseline variables between the two groups with the exception of the number of pregnancies (2.5 +/- 1.5 vs 0, p = 0.0002). Two patients in each group died during the first 6 months after transplantation, and one in each group died later. Actuarial survival rates were 75% +/- 15% and 78% +/- 14% (p = NS) at 1 year and 60% +/- 18% and 78% +/- 14% (p = NS) at 5 years in PPCM and IDCM patients, respectively. Linearized rejection rates during the first 3 months were 1.85 +/- 0.56 and 1.91 +/- 0.49 (p = NS) and during the second 3 months were 0.18 +/- 0.18 and 0.45 +/- 0.26 (p = NS), respectively. Similarly no significant differences in linearized infection rates were found. Among patients surviving more than 6 months after transplantation, after a mean follow-up period of 4.5 +/- 3.1 years for those with PPCM and 7.8 +/- 3.2 years for those with IDCM, 83% and 100%, respectively, were rehabilitated; hemodynamic findings were normal in all patients and the frequency of other transplant-associated complications was similar in both groups. In conclusion, heart transplantation is a valuable option for patients with PPCM and severe congestive heart failure that is unresponsive to conventional treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Peripartum cardiomyopathy--three cases

Three cases of peripartum cardiomyopathy (PPCM) are presented, each illustrating a clinically important aspect of the disorder. One patient survived despite extreme haemodynamic deterioration, one died suddenly 2 months post partum although clinically recovered, and one died during a subsequent pregnancy. The cases demonstrate the severity and the unpredictable course of PPCM, which remains a challenge both to scientists and to clinicians.