Myocarditis and long-term survival in peripartum cardiomyopathy

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.

Serum Proteomic Analysis of Peripartum Cardiomyopathy Reveals Distinctive Dysregulation of Inflammatory and Cholesterol Metabolism Pathways

BACKGROUND

The pathophysiology of peripartum cardiomyopathy (PPCM) and its distinctive biological features remain incompletely understood. High-throughput serum proteomic profiling, a powerful tool to gain insights into the pathophysiology of diseases at a systems biology level, has never been used to investigate PPCM relative to nonischemic cardiomyopathy.

OBJECTIVES

The aim of this study was to characterize the pathophysiology of PPCM through serum proteomic analysis.

METHODS

Aptamer-based proteomic analysis (SomaScan 7K) was performed on serum samples from women with PPCM (n = 67), women with nonischemic nonperipartum cardiomyopathy (NPCM) (n = 31), and age-matched healthy peripartum and nonperipartum women (n = 10 each). Serum samples were obtained from the IPAC (Investigation of Pregnancy-Associated Cardiomyopathy) and IMAC2 (Intervention in Myocarditis and Acute Cardiomyopathy) studies.

RESULTS

Principal component analysis revealed unique clustering of each patient group (P for difference <0.001). Biological pathway analyses of differentially measured proteins in PPCM relative to NPCM, before and after normalization to pertinent healthy controls, highlighted specific dysregulation of inflammatory pathways in PPCM, including the upregulation of the cholesterol metabolism-related anti-inflammatory pathway liver-X receptor/retinoid-X receptor (LXR/RXR) (P < 0.01, Z-score 1.9-2.1). Cardiac recovery by 12 months in PPCM was associated with the downregulation of pro-inflammatory pathways and the upregulation of LXR/RXR, and an additional RXR-dependent pathway involved in the regulation of inflammation and metabolism, peroxisome proliferator-activated receptor α/RXRα signaling.

CONCLUSIONS

Serum proteomic profiling of PPCM relative to NPCM and healthy controls indicated that PPCM is a distinct disease entity characterized by the unique dysregulation of inflammation-related pathways and cholesterol metabolism-related anti-inflammatory pathways. These findings provide insight into the pathophysiology of PPCM and point to novel potential therapeutic targets.

Meta-Analysis of Long-Term (>1 Year) Cardiac Outcomes of Peripartum Cardiomyopathy

Peripartum cardiomyopathy is the development of heart failure toward the end of pregnancy or in the months after delivery in the absence of other attributable causes, with left ventricular systolic dysfunction and a left ventricular ejection fraction (LVEF) generally <45%. Given that patients are relatively young at the time of diagnosis, this study was performed to summarize current evidence surrounding the long-term cardiac outcomes. MEDLINE, Embase, Cochrane CENTRAL, and CINAHL were searched for original studies that reported long-term (>1 year) patient outcomes. Of the 3,144 total records identified, 62 studies involving 4,282 patients met the selection criteria. The mean LVEF was 28% at diagnosis and 47% at the time of the last follow-up. Approximately half of the patients achieved myocardial recovery (47%), most commonly defined as an LVEF >50% (n = 21). The prevalence of implantable cardioverter-defibrillator use, left ventricular assist device implantation, and heart transplantation was 12%, 7%, and 11%, respectively. The overall all-cause mortality was 9%, and despite having more cardiovascular risk factors, patients residing in high-income countries had superior outcomes, including reduced rates of mortality.

Pathological features of biopsied myocardium in patients clinically diagnosed with peripartum cardiomyopathy

The etiology of peripartum cardiomyopathy (PPCM) is unknown. Therefore, we evaluated the etiology of patients clinically diagnosed with PPCM using endomyocardial biopsy. We studied five patients diagnosed with PPCM following endomyocardial biopsy (age, 28-42 years; mean age, 35 years). Biopsied samples were evaluated using microscopy, including immunostaining and electron microscopy. The pathological findings were as follows: myocardial hypertrophy, myocardial fibrosis, and cell infiltration. Two patients were diagnosed with lymphocytic myocarditis, one with eosinophilic myocarditis, one with hypertensive heart disease, and one with a combination of hypertension and myocarditis. Endomyocardial biopsy suggested that the causes of PPCM were varied and related to myocarditis and myocardial overload due to hypertension.

The Relationship Between Peripartum Cardiomyopathy and Preeclampsia – Pathogenesis, Diagnosis and Management

Peripartum cardiomyopathy (PPCM) is a condition with an incompletely understood etiology, although many risk factors for this disorder have been mentioned. Preeclampsia (PE) is a rare but undoubtedly very important cause of PPCM. Early recognition and prompt treatment of preeclampsia and peripartum cardiomyopathy are essential to optimize pregnancy outcomes. An extensive manual search of major electronic databases was conducted in November 2021. The following literature review provides a comprehensive discussion of peripartum cardiomyopathy and preeclampsia and quantifies the prevalence of PE in women with PPCM. The authors highlighted aspects such as epidemiology, risk factors, cardiovascular changes, diagnosis and clinical presentation, and management and complications. Accumulating data indicate that both conditions have a similar pathogenesis characterized by vascular abnormalities. In both conditions we can observe an increase in interleukin-6 and gamma interferon, CCL2/MCP1, and decreased SOD activity. sFLT1 (a soluble form of fms-like tyrosine kinase 1), a substance with antiangiogenic and probably cardiotoxic effects, may be important. Preeclampsia and peripartum cardiomyopathy are characterized by recurrence rates that follow a similar pattern in subsequent pregnancies, and mortality remains a concern. Our analysis highlights the need to better understand the co-morbidity of PE and PPCM, and the need to qualify patients for the same clinical trials because of the common origin of these conditions.

Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a form of heart failure that occurs toward the end of pregnancy or in the months following pregnancy and is marked by left ventricular systolic dysfunction. The cause of PPCM remains unknown and there is no diagnostic test specific to PPCM. Outcomes vary and include complete left ventricular recovery, persistent cardiac dysfunction, transplant, and death. Numerous advances have been made in understanding this disease, but many knowledge gaps remain. This article reviews recent data and recommendations for clinical practice in addition to highlighting the multiple knowledge gaps related to PPCM that warrant further investigation.

Cleavage and Sub-Cellular Redistribution of Nuclear Pore Protein 98 by Coxsackievirus B3 Protease 2A Impairs Cardioprotection

Myocarditis, inflammation of the heart muscle, affects all demographics and is a major cause of sudden and unexpected death in young people. It is most commonly caused by viral infections of the heart, with coxsackievirus B3 (CVB3) being among the most prevalent pathogens. To understand the molecular pathogenesis of CVB3 infection and provide strategies for developing treatments, we examined the role of a key nuclear pore protein 98 (NUP98) in the setting of viral myocarditis. NUP98 was cleaved as early as 2 h post-CVB3 infection. This cleavage was further verified through both the ectopic expression of viral proteases and in vitro using purified recombinant CVB3 proteases (2A and 3C), which demonstrated that CVB3 2A but not 3C is responsible for this cleavage. By immunostaining and confocal imaging, we observed that cleavage resulted in the redistribution of NUP98 to punctate structures in the cytoplasm. Targeted siRNA knockdown of NUP98 during infection further increased viral protein expression and viral titer, and reduced cell viability, suggesting a potential antiviral role of NUP98. Moreover, we discovered that expression levels of neuregulin-1 (NRG1), a cardioprotective gene, and presenilin-1 (PSEN1), a cellular protease processing the tyrosine kinase receptor ERBB4 of NRG1, were reliant upon NUP98 and were downregulated during CVB3 infection. In addition, expression of these NUP98 target genes in myocardium tissue not only occurred at an earlier phase of infection, but also appeared in areas away from the initial inflammatory regions. Collectively, CVB3-induced cleavage of NUP98 and subsequent impairment of the cardioprotective NRG1-ERBB4/PSEN1 signaling cascade may contribute to increased myocardial damage in the context of CVB3-induced myocarditis. To our knowledge, this is the first study to demonstrate the link between NUP98 and the NRG1 signaling pathway in viral myocarditis.

Peripartum Serial Echocardiographic Findings in a Patient with Life-threatening Peripartum Cardiomyopathy

A 35-year-old woman was referred to our hospital for the management of acutely decompensated heart failure due to peripartum cardiomyopathy (PPCM). Generally, cardiac examinations are performed after the manifestation of heart failure in patients with PPCM. Thus, reports of serial cardiac examinations before the onset of PPCM are scarce. In this case, we were able to document the serial echocardiographic findings before the onset of life-threatening PPCM. We found that the left ventricular systolic function was preserved at 35 weeks of gestation but declined acutely after delivery at 38 weeks. Although speculative, these findings suggest that left ventricular dilation might precede the onset of PPCM.

New Insights in Peripartum Cardiomyopathy

Significant progress in understanding the pathophysiology of peripartum cardiomyopathy, especially hormonal and genetic mechanisms, has been made. Specific criteria should be used for diagnosis, but the disease remains a diagnosis of exclusion. Both long-term and recurrent pregnancy prognoses depend on recovery of cardiac function. Data from large registries and randomized controlled trials of evidence-based therapeutics hold promise for future improved clinical outcomes.

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

OBJECTIVES

Peripartum cardiomyopathy (PPCM) is a serious complication of pregnancy. Studies investigating the risk factors that worsen outcomes have yielded conflicting results. The goals of this study were to describe the clinical and echocardiographic characteristics of PPCM in a single tertiary center and to determine the prognostic factors associated with persistence of left ventricular (LV) dysfunction in these women.

STUDY DESIGN

This retrospective cross-sectional population-based cohort study included all patients with PPCM confirmed by echocardiography who delivered at our center from 2004 to 2014. Two groups were compared to determine long-term maternal outcome: (1) those who recovered normal LV function; and (2) those with residual systolic LV dysfunction.

RESULTS

There were 148,994 deliveries during the study period. Of these, 89,196 patients were Bedouin and 59,798 were non-Bedouin. Forty-six patients met the PPCM study inclusion criteria. The PPCM prevalence for the total deliveries was 1:3,239. The PPCM prevalence among Bedouin patients was 1:2,787 versus non-Bedouin patients of 1:4,983 (P=0.037). None of the women had pre-existing chronic hypertension, and there was no maternal death. Patients who had severe or moderate LV dysfunction at the clinical presentation of PPCM were less likely to regain normal LV function than those with mild dysfunction (81.2% versus 56.7%, P=0.009). Based on initial echocardiogram, a trend toward residual LV dysfunction was noted in patients with a dilated left ventricle as compared to those with a non-dilated left ventricle (18.8% versus 6.7%, P=0.32). A hypokinetic right ventricle was found in 15.2% of the women who suffered from PPCM.

CONCLUSION

In our cohort, Bedouin women may be at increased risk for PPCM, and patients with severe LV dysfunction have a lower chance of recovery from PPCM.

Long-term prognosis, subsequent pregnancy, contraception and overall management of peripartum cardiomyopathy: practical guidance paper from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy

Peripartum cardiomyopathy is an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause for heart failure is identified. Outcome varies from full recovery to residual left ventricular systolic dysfunction and even death. Many women return to their physician to acquire information on their long-term prognosis, to seek medical advice regarding contraception, or when planning a subsequent pregnancy. This position paper summarizes current evidence for long-term outcome, risk stratification of further pregnancies and overall management. Based on the best available evidence, as well as the clinical experience of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy members, a consensus on pre- and postpartum management algorithms for women undergoing a subsequent pregnancy is presented.

The innate immune system in chronic cardiomyopathy: a European Society of Cardiology (ESC) scientific statement from the Working Group on Myocardial Function of the ESC

Activation of the immune system in heart failure (HF) has been recognized for over 20 years. Initially, experimental studies demonstrated a maladaptive role of the immune system. However, several phase III trials failed to show beneficial effects in HF with therapies directed against an immune activation. Preclinical studies today describe positive and negative effects of immune activation in HF. These different effects depend on timing and aetiology of HF. Therefore, herein we give a detailed review on immune mechanisms and their importance for the development of HF with a special focus on commonalities and differences between different forms of cardiomyopathies. The role of the immune system in ischaemic, hypertensive, diabetic, toxic, viral, genetic, peripartum, and autoimmune cardiomyopathy is discussed in depth. Overall, initial damage to the heart leads to disease specific activation of the immune system whereas in the chronic phase of HF overlapping mechanisms occur in different aetiologies.

Circulating T-Cell Subsets, Monocytes, and Natural Killer Cells in Peripartum Cardiomyopathy: Results From the Multicenter IPAC Study

OBJECTIVE

The aim of this work was to evaluate the hypothesis that the distribution of circulating immune cell subsets, or their activation state, is significantly different between peripartum cardiomyopathy (PPCM) and healthy postpartum (HP) women.

BACKGROUND

PPCM is a major cause of maternal morbidity and mortality, and an immune-mediated etiology has been hypothesized. Cellular immunity, altered in pregnancy and the peripartum period, has been proposed to play a role in PPCM pathogenesis.

METHODS

The Investigation of Pregnancy-Associated Cardiomyopathy (IPAC) study enrolled 100 women presenting with a left ventricular ejection fraction of <0.45 within 2 months of delivery. Peripheral T-cell subsets, natural killer (NK) cells, and cellular activation markers were assessed by flow cytometry in PPCM women early (<6 wk), 2 months, and 6 months postpartum and compared with those of HP women and women with non-pregnancy-associated recent-onset cardiomyopathy (ROCM).

RESULTS

Entry NK cell levels (CD3-CD56+CD16+; reported as % of CD3- cells) were significantly (P < .0003) reduced in PPCM (6.6 ± 4.9% of CD3- cells) compared to HP (11.9 ± 5%). Of T-cell subtypes, CD3+CD4-CD8-CD38+ cells differed significantly (P < .004) between PPCM (24.5 ± 12.5% of CD3+CD4-CD8- cells) and HP (12.5 ± 6.4%). PPCM patients demonstrated a rapid recovery of NK and CD3+CD4-CD8-CD38+ cell levels. However, black women had a delayed recovery of NK cells. A similar reduction of NK cells was observed in women with ROCM.

CONCLUSIONS

Compared with HP control women, early postpartum PPCM women show significantly reduced NK cells, and higher CD3+CD4-CD8-CD38+ cells, which both normalize over time postpartum. The mechanistic role of NK cells and "double negative" (CD4-CD8-) T regulatory cells in PPCM requires further investigation.

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.

A contemporary review of peripartum cardiomyopathy

Peripartum cardiomyopathy reflects the presence of cardiac failure in the absence of determinable heart disease and occurs in late third trimester of pregnancy or up to 6 months postpartum. A full understanding of pathophysiological mechanisms is lacking, but excess prolactin levels, haemodynamic alterations, inflammation and nutritional deficiencies have all been implicated. Its clinical presentation has distinct overlap with physiological alterations in healthy pregnancy and this presents a diagnostic challenge. However, echocardiography can provide significant benefit in accurate assessment and narrowing of differentials. Pharmacotherapy is broadly aligned with established guidelines for cardiac failure, but specific therapies are indicated for treatment of clinical sequelae. Moreover, an individualistic approach is required based on clinical context to manage delivery. Further research appears imperative to optimise management strategies and reduce disease burden.

Women's Experiences Being Diagnosed With Peripartum Cardiomyopathy: A Qualitative Study

INTRODUCTION

Cardiovascular disease has been identified as the leading cause of maternal mortality in the United States, with cardiomyopathy, including peripartum cardiomyopathy (PPCM), accounting for 12% to 16% of all pregnancy-related deaths. The purpose of this study was to describe women's experiences being diagnosed with PPCM.

METHODS

This investigation was conducted using a qualitative design. We collected publicly available narratives posted by 92 women with PPCM (mean [SD] age 29 [6] years, mean [SD] ejection fraction 25.5 [10.8]%) in 3 online support groups. Data were coded and thematically organized so as to produce a richly detailed account of this experience.

RESULTS

The experience of diagnosis was marked by the women's distinct memories of their initial symptoms and whether they were dismissed or taken seriously. The most commonly reported symptoms were extreme shortness of breath, orthopnea, tachycardia, palpitations, chest pain, cough, and edema. Nearly 40% of women experienced symptom dismissal by health care providers. One-fourth of women were initially given inaccurate diagnoses ranging from "new mom anxiety" to asthma. Women described their initial reaction to diagnosis as feeling terrified, devastated, and feeling a sense of doom. Women had difficulty caring for their newborns during the postpartum period, and they struggled with the medical advice they received to not get pregnant again.

DISCUSSION

Despite experiencing severe subjective and objective symptoms, nearly 40% of women with PPCM experienced symptom dismissal by health care providers, in part due to the overlap between normal symptoms of pregnancy or the postpartum period and symptoms of heart failure.

Myocardial T1 maps reflect histological findings in acute and chronic stages of myocarditis in a rat model

BACKGROUND

Cardiovascular magnetic resonance offers both diagnostic and prognostic information in myocarditis. Using an established animal model of myocarditis, the aim of this study was to measure myocardial T1 before the onset, in the acute and in the chronic phases of the disease and to compare its course with histological and immunohistochemistry findings.

METHODS

Male young Lewis rats were immunized with 0.25 mg porcine myocardial myosin into the rear footpads on day 0. Native and contrast-enhanced ECG-triggered cardiac MRI examinations were performed before immunization on day 0 and on days 14, 21 and 35. Left ventricular function, pre- and post- contrast T1 parameters and LGE images were assessed using Small animal look-locker inversion recovery (SALLI). For each of the indicated time points a minimum of 4 rats were randomly sacrificed for pathological investigations including conventional histology (HE and Sirius-Red staining) and immunohistochemistry (CD 68) investigations.

RESULTS

All immunized rats developed myocarditis (morbidity 100%). Histologically we observed increased wall thickness with biventricular macrophage-rich mixed inflammatory infiltrates. All rats with a histologically severe myocarditis showed increased native T1 and decreased post-contrast T1 of the myocardium.

CONCLUSIONS

The assessment of native T1 and post-contrast T1 allows accurate differentiation between healthy myocardium and myocardium with inflammation and also between the acute and chronic phases of the disease.

Peripartum Cardiomyopathy in Intensive Care Unit: An Update

Peripartum cardiomyopathy (PPCM) is a systolic heart failure that occurs during the last month of pregnancy or within 5 months after delivery. It is an uncommon disease of unknown etiopathogenesis and has a very high rate of maternal mortality. Because of similarity between symptoms of PPCM and physiological discomforts during pregnancy, the early diagnosis of PPCM presents a major challenge. Since hemodynamic changes during PPCM can vitally jeopardize the mother and the fetus, patients with severe forms of PPCM require a multidisciplinary approach in intensive care units. This review summarizes the current state of knowledge about the diagnosis, monitoring, and the treatment of PPCM. Having reviewed the recent researches, it gives insight into the new treatment strategies of this rare disease.

Peri-partum cardiomyopathy in a pregnant woman at term revealed by acute pulmonary edema: what to do in front this catastrophic situation?

Peripartum cardiomyopathy is insufficient congestive heart occurring in the last month of pregnancy and 5 months after delivery, in the absence of preexisting heart disease and identified etiology. This heart disease is associated with echocardiography systolic dysfunction and left ventricular dilatation. Its incidence ranges from 1/3000 to 1/15000, depending on the region, including much higher in some African countries, it particularly concern women over 30 years, multiparous and multiple pregnancies. The pathogenesis remains unclear, the prognosis is closely related to the complete recovery of cardiac function. We report through the clinical case of a woman aged 33 years admitted to the ICU for acute pulmonary edema of sudden onset of a term pregnancy and what to do before this critical situation.

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.

Mortality and morbidity in different immunization protocols for experimental autoimmune myocarditis in rats

AIM

We aimed to investigate the histological and clinical presentations of experimental autoimmune myocarditis (EAM) induced by different immunization schemes.

METHODS

Male young Lewis rats were divided into five groups immunized by porcine myocardial myosin: subcutaneously (SC) 2 mg (in two 1-mg doses on day 0 and 7), 0 mg (sham group) subcutaneously into rear footpads (RF), 0.25 mg RF, 0.5 mg RF or 1 mg RF (all RF once on day 0). On day 21, left ventricular (LV) function was assessed by cardiac magnetic resonance imaging and cardiac catheterization. The type and degree of myocardial inflammatory infiltrates were determined by conventional histology and immunohistochemistry.

RESULTS

In the SC immunized rats and in the RF sham group, we observed 0% mortality, while in the actively RF immunized rats, mortality was 20, 20 and 44% for the 0.25 mg, 0.5 mg and 1 mg myosin doses respectively. Morbidity as defined by inflammatory infiltrates on haematoxylin and eosin (HE) staining was 22% in the SC immunized rats, 0% in the RF sham group and 100% in all actively RF immunized groups. We observed augmented relative ventricle weight and spleen weight, increased LV end-diastolic pressure, reduced LV developed pressure and reduced LV ejection fraction in all with myosin-immunized RF groups without any systematic dose effect.

CONCLUSION

Subcutaneous immunization to the neck and flanks did not induce a reproducible EAM, while RF myosin administration reliably led to EAM. Lower myosin doses seem to induce the complete histological and clinical picture of EAM while being associated with lower mortality, non-specific symptoms and animal distress.

Role of cardiac magnetic resonance in the evaluation of dilated cardiomyopathy: diagnostic contribution and prognostic significance

Dilated cardiomyopathy (DCM) represents the final common morphofunctional pathway of various pathological conditions in which a combination of myocyte injury and necrosis associated with tissue fibrosis results in impaired mechanical function. Recognition of the underlying aetiology of disease and accurate disease monitoring may be crucial to individually optimize therapeutic strategies and stratify patient's prognosis. In this regard, CMR has emerged as a new reference gold standard providing important information for differential diagnosis and new insight about individual risk stratification. The present review article will focus on the role of CMR in the evaluation of present condition, analysing respective strengths and limitations in the light of current literature and technological developments.

The relationship between pre-eclampsia and peripartum cardiomyopathy: a systematic review and meta-analysis

OBJECTIVES

The goal of this study was to systematically review the peripartum cardiomyopathy (PPCM) literature and determine the prevalence of pre-eclampsia (PE) in women with PPCM. Secondary analyses included evaluation of the prevalence of hypertensive disorders, multiple gestations, and multiparity.

BACKGROUND

PPCM is a significant cause of maternal and infant morbidity and mortality worldwide, yet its etiology remains unknown. PE is often cited as a risk factor for the development of PPCM and recent research suggests that PE and PPCM share mechanisms that contribute to their pathobiology. No comprehensive evaluation of the relationship between PE and PPCM exists.

METHODS

A systematic predetermined search strategy was performed in multiple databases to identify studies describing ≥3 women with PPCM. Prevalence rates of PE, hypertension, multiple gestations, and multiparity were pooled.

RESULTS

Data from 22 studies (n = 979) were included in this analysis. The pooled prevalence of 22% (95% confidence interval [CI]: 16% to 28%) was more than quadruple the 5% average worldwide background rate of PE in pregnancy (p < 0.001). There were no geographic or racial differences detected in the prevalence of PE in women with PPCM. The rates of hypertension during pregnancy (37% [95% CI: 29% to 45%]) and multiple gestations (9% [95% CI: 7% to 11%]) were also elevated.

CONCLUSIONS

The prevalence of PE, hypertensive disorders, and multiple gestations in women with PPCM is markedly higher than that in the general population. These findings support the concept of a shared pathogenesis between PE and PPCM and highlight the need for awareness of the overlap between these 2 diseases.

Peripartum cardiomyopathy: a review

Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy of unclear etiology affecting women without preexisting heart disease during the last month of pregnancy or during the first 5 months postpartum. Its incidence shows marked geographic and ethnic variation, being most common in Africa and among women of African descent. Most women present in the first month postpartum with typical heart failure symptoms such as dyspnea, lower extremity edema, and fatigue. These symptoms are often initially erroneously diagnosed as part of the normal puerperal process. Diagnosis can be aided by the finding of a significantly elevated serum brain natriuretic peptide. The etiology of PPCM is unclear; however, recent research suggests abnormal prolactin metabolism is seminal in its development, and prolactin antagonism with bromocriptine shows promise as a novel treatment for PPCM.

Risk factors for maternal outcome in pregnancy complicated with dilated cardiomyopathy

OBJECTIVE

The goal of the study was to determine risk factors for maternal cardiac failure in pregnancy complicated with dilated cardiomyopathy (DCM).

STUDY DESIGN

The subjects were 29 patients diagnosed with DCM before conception or during the first 7 months of pregnancy. DCM was defined as left ventricle end-diastolic dimension (LVDd)≥48 mm and/or fractional shortening (%FS)≤30% on echocardiography. Patients were followed until at least 1 year after delivery and were categorized into a poor prognosis group (n=6; death or end stage heart failure of New York Heart Association (NYHA) class III and IV) and a good prognosis group (n=23; all other cases).

RESULT

DCM was initially diagnosed during pregnancy in 6/6 and 8/23 patients in the poor and good prognosis groups, respectively (P<0.005). The %FS of the first test during pregnancy was 17.5±6.2 and 27.4±9.3% in the respective groups (P<0.005). In eight abortion cases with %FS 15.2±3.1%, %FS, cardiac function and NYHA class were maintained until 20 months after abortion. There was no relationship between LVDd and maternal outcome.

CONCLUSION

Onset during pregnancy and decreased %FS are risk factors for a poor maternal outcome in patients with DCM. Abortion prevents further deterioration of cardiac function in patients with a very low %FS.

Peripartum cardiomyopathy: review and practice guidelines

Peripartum cardiomyopathy, a type of dilated cardiomyopathy of unknown origin, occurs in previously healthy women in the final month of pregnancy and up to 5 months after delivery. Although the incidence is low-less than 0.1% of pregnancies -morbidity and mortality rates are high at 5% to 32%. The outcome of peripartum cardiomyopathy is also highly variable. For some women, the clinical and echocardiographic status improves and sometimes returns to normal, whereas for others, the disease progresses to severe cardiac failure and even sudden cardiac death. In acute care, treatment may involve the use of intravenous vasodilators, inotropic medications, an intra-aortic balloon pump, ventricular-assist devices, and/or extracorporeal membrane oxygenation. Survivors of peripartum cardiomyopathy often recover from left ventricular dysfunction; however, they may be at risk for recurrence of heart failure and death in subsequent pregnancies. Women with chronic left ventricular dysfunction should be managed according to guidelines of the American College of Cardiology Foundation and the American Heart Association.

Myocardial recovery in peripartum cardiomyopathy: prospective comparison with recent onset cardiomyopathy in men and nonperipartum women

BACKGROUND

Whether myocardial recovery occurs more frequently in peripartum cardiomyopathy (PPCM) than in recent onset cardiomyopathies in men and nonperipartum women has not been prospectively evaluated. This was examined through an analysis of outcomes in the Intervention in Myocarditis and Acute Cardiomyopathy 2 (IMAC2) registry.

METHODS AND RESULTS

IMAC2 enrolled 373 subjects with recent onset nonischemic dilated cardiomyopathy. Left ventricular ejection fraction (LVEF) was assessed at entry and 6 months, and subjects followed for up to 4 years. Myocardial recovery was compared between men (group 1), nonperipartum women (group 2) and subjects with PPCM (group 3). The cohort included 230 subjects in group 1, 104 in group 2, and 39 in group 3. The mean LVEF at baseline in groups 1, 2, and 3 was 0.23 ± 0.08, 0.24 ± 0.08, and 0.27 ± 0.07 (P = .04), and at 6 months was 0.39 ± 0.12, 0.42 ± 0.11, and 0.45 ± 0.14 (P = .007). Subjects in group 3 had a much greater likelihood of achieving an LVEF >0.50 at 6 months than groups 1 or 2 (19 %, 34%, and 48% respectively, P = .002).

CONCLUSIONS

Prospective evaluation confirms myocardial recovery is greatest in women with PPCM, poorest in men, and intermediate in nonperipartum women. On contemporary therapy, nearly half of women with PPCM normalize cardiac function by 6 months.

2011 consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology

The Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology have produced this position paper concerning the current role of endomyocardial biopsy (EMB) for the diagnosis of cardiac diseases and its contribution to patient management, focusing on pathological issues, with these aims: • Determining appropriate EMB use in the context of current diagnostic strategies for cardiac diseases and providing recommendations for its rational utilization • Providing standard criteria and guidance for appropriate tissue triage and pathological analysis • Promoting a team approach to EMB use, integrating the competences of pathologists, clinicians, and imagers.

Proteomic and biochemical analyses reveal the activation of unfolded protein response, ERK-1/2 and ribosomal protein S6 signaling in experimental autoimmune myocarditis rat model

BACKGROUND

To investigate the molecular and cellular pathogenesis underlying myocarditis, we used an experimental autoimmune myocarditis (EAM)-induced heart failure rat model that represents T cell mediated postinflammatory heart disorders.

RESULTS

By performing unbiased 2-dimensional electrophoresis of protein extracts from control rat heart tissues and EAM rat heart tissues, followed by nano-HPLC-ESI-QIT-MS, 67 proteins were identified from 71 spots that exhibited significantly altered expression levels. The majority of up-regulated proteins were confidently associated with unfolded protein responses (UPR), while the majority of down-regulated proteins were involved with the generation of precursor metabolites and energy metabolism in mitochondria. Although there was no difference in AKT signaling between EAM rat heart tissues and control rat heart tissues, the amounts and activities of extracellular signal-regulated kinase (ERK)-1/2 and ribosomal protein S6 (rpS6) were significantly increased. By comparing our data with the previously reported myocardial proteome of the Coxsackie viruses of group B (CVB)-mediated myocarditis model, we found that UPR-related proteins were commonly up-regulated in two murine myocarditis models. Even though only two out of 29 down-regulated proteins in EAM rat heart tissues were also dysregulated in CVB-infected rat heart tissues, other proteins known to be involved with the generation of precursor metabolites and energy metabolism in mitochondria were also dysregulated in CVB-mediated myocarditis rat heart tissues, suggesting that impairment of mitochondrial functions may be a common underlying mechanism of the two murine myocarditis models.

CONCLUSIONS

UPR, ERK-1/2 and S6RP signaling were activated in both EAM- and CVB-induced myocarditis murine models. Thus, the conserved components of signaling pathways in two murine models of acute myocarditis could be targets for developing new therapeutic drugs or methods aimed at treating enigmatic myocarditis.

Recovery from peripartum cardiomyopathy in a Japanese woman after administration of bromocriptine as a new treatment option

Peripartum cardiomyopathy (PPCM) is a form of heart failure that occurs in women within 1 month before delivery and 5 months after delivery. The outcome of PPCM is variable but improves significantly when appropriate medication is administered in the acute phase; furthermore, the outcome does not worsen even after discontinuation of therapy in the chronic phase. The symptoms and signs of PPCM are similar to those of idiopathic dilated cardiomyopathy. The medical management of patients with PPCM is similar to that for other other forms of heart failure. Recent experimental data implicate a casual role of prolactin in the development of PPCM. Prolactin secretion can be reduced with bromocriptine which had beneficial effects in a small study. We present a Japanese woman with acute PPCM treated with bromocriptine as a therapeutic option. Following treatment, the serum prolactin levels dropped swiftly. Concurrently, LV function improved, and heart failure symptoms decreased, accompanied by a decrease in the BNP level.