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Pubblicazioni recenti - peripartum cardiomyopathy
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Long-term discontinuation of warfarin in a patient with HeartMate 3 left ventricular assist device without complication.
J Card Surg2019 Nov;():. doi: 10.1111/jocs.14352.
Fiedler Amy G, Hermsen Joshua L, Smith Jason W, Dhingra Ravi,
Abstract
A 38-year-old woman with peripartum cardiomyopathy underwent placement of a HeartMate 3 (HM3) left ventricular assist device (LVAD). Postoperatively, she refused warfarin therapy and was maintained on aspirin monotherapy for 19 months. She did not experience thrombotic or thromboembolic complications associated with lack of oral vitamin K antagonist anticoagulation. Our patient represents the longest reported duration of a patient with HM3 LVAD maintained without warfarin without evidence of thrombotic or thromboembolic events.
© 2019 Wiley Periodicals, Inc.
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Long-term follow-up in peripartum cardiomyopathy patients with contemporary treatment: low mortality, high cardiac recovery, but significant cardiovascular co-morbidities.
Eur J Heart Fail2019 Nov;():. doi: 10.1002/ejhf.1624.
Moulig Valeska, Pfeffer Tobias Jonathan, Ricke-Hoch Melanie, Schlothauer Stella, Koenig Tobias, Schwab Johannes, Berliner Dominik, Pfister Roman, Michels Guido, Haghikia Arash, Falk Christine S, Duncker David, Veltmann Christian, Hilfiker-Kleiner Denise, Bauersachs Johann,
Abstract
AIMS:
Peripartum cardiomyopathy (PPCM) establishes late in pregnancy or in the first postpartum months. Many patients recover well within the first year, but long-term outcome studies on morbidity and mortality are rare. Here, we present 5-year follow-up data of a German PPCM cohort.
METHODS AND RESULTS:
Five-year follow-up data were available for 66 PPCM patients (mean age 34?±?5?years) with a mean left ventricular ejection fraction (LVEF) of 26?±?9% at diagnosis. Ninety-eight percent initially received standard heart failure therapy (beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and/or mineralocorticoid receptor antagonists), and 86% were additionally treated with dopamine D2 receptor agonists (mainly bromocriptine) and anticoagulation. After 1?year, mean LVEF had improved to 50?±?11% (n = 48) and further increased to 54?±?7% at 5-year follow-up with 72% of patients having achieved full cardiac recovery (LVEF >50%). At 5-year follow-up, only three patients (5%) displayed no recovery, of whom one had died. However, 20% had arterial hypertension and 17% arrhythmias, including paroxysmal supraventricular tachycardia, ventricular tachycardia, or ventricular fibrillation. Moreover, 70% were still on at least one heart failure drug. Subsequent pregnancy occurred in 16 patients with two abortions and 14 uneventful pregnancies. Mean LVEF was 55?±?7% at 5-year follow-up in these patients.
CONCLUSION:
Our PPCM collective treated with standard therapy for heart failure, dopamine D2 receptor agonists, and anticoagulation displays a high and stable long-term recovery rate with low mortality at 5-year follow-up. However, long-term use of cardiovascular medication, persisting or de novo hypertension and arrhythmias were frequent.
© 2019 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.
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In peripartum cardiomyopathy Plasminogen Activator Inhibitor-1 is a potential new biomarker with controversial roles.
Cardiovasc Res2019 Nov;():. doi: cvz300.
Ricke-Hoch Melanie, Hoes Martijn F, Pfeffer Tobias J, Schlothauer Stella, Nonhoff Justus, Haidari Susanna, Bomer Nils, Scherr Michaela, Stapel Britta, Stelling Elisabeth, Kiyan Yulia, Falk Christine, Haghikia Arash, Binah Ofer, Arany Zolt, Thum Thomas, Bauersachs Johann, van der Meer Peter, Hilfiker-Kleiner Denise,
Abstract
AIMS:
Peripartum cardiomyopathy (PPCM) is a life-threatening heart disease occurring in previously healthy women. A common pathomechanism in PPCM involves the angiostatic 16kDa-prolactin (16kDa-PRL) fragment, which via NF-?B-mediated upregulation of microRNA-(miR)-146a induces vascular damage and heart failure. We analyze whether the plasminogen-activator-inhibitor-1 (PAI-1) is involved in PPCM pathophysiology.
METHODS/RESULTS:
In healthy age-matched postpartum women (PP-Ctrl, n?=?53, left-ventricular-ejection-fraction, LVEF>55%), PAI-1 plasma levels were within the normal range (21±10?ng/ml), but significantly elevated (64±38?ng/ml, p?
CONCLUSION:
In PPCM patients, circulating and cardiac PAI-1 expression are upregulated. While circulating PAI-1 may add 16kDa-PRL to induce vascular impairment via the uPAR/NF-?B/miR-146a pathway, experimental data suggest that cardiac PAI-1 expression seems to protect the PPCM heart from fibrosis. Thus, measuring circulating PAI-1 and miR-146a, together with an uPAR/NF-?B-activity assay could be developed into a specific diagnostic marker assay for PPCM, but unrestricted reduction of PAI-1 for therapy may not be advised.
TRANSLATIONAL PERSPECTIVE:
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions please email: journals.permissions@oup.com.
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An Update on the Multifaceted Roles of STAT3 in the Heart.
Front Cardiovasc Med2019 ;6():150. doi: 10.3389/fcvm.2019.00150.
Harhous Zeina, Booz George W, Ovize Michel, Bidaux Gabriel, Kurdi Mazen,
Abstract
Signal transducer and activator of transcription 3 (STAT3) is a signaling molecule and transcription factor that plays important protective roles in the heart. The protection mediated by STAT3 is attributed to its genomic actions as a transcription factor and other non-genomic roles targeting mitochondrial function and autophagy. As a transcription factor, STAT3 upregulates genes that are anti-oxidative, anti-apoptotic, and pro-angiogenic, but suppresses anti-inflammatory and anti-fibrotic genes. Its suppressive effects on gene expression are achieved through competing with other transcription factors or cofactors. STAT3 is also linked to the modification of mRNA expression profiles in cardiac cells by inhibiting or inducing miRNA. In addition to these genomic roles, STAT3 is suggested to function protectively in mitochondria, where it regulates ROS production, in part by regulating the activities of the electron transport chain complexes, although our recent evidence calls this role into question. Nonetheless, STAT3 is a key player known to be activated in the cardioprotective ischemic conditioning protocols. Through these varied roles, STAT3 participates in various mechanisms that contribute to cardioprotection against different heart pathologies, including myocardial infarction, hypertrophy, diabetic cardiomyopathy, and peripartum cardiomyopathy. Understanding how STAT3 is involved in the protective mechanisms against these different cardiac pathologies could lead to novel therapeutic strategies to treat them.
Copyright © 2019 Harhous, Booz, Ovize, Bidaux and Kurdi.
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Importance of Early Diagnosis in Peripartum Cardiomyopathy.
Hypertension2019 Nov;():HYPERTENSIONAHA11913291. doi: 10.1161/HYPERTENSIONAHA.119.13291.
Lewey Jennifer, Levine Lisa D, Elovitz Michal A, Irizarry Olga C, Arany Zoltan,
Abstract
Peripartum cardiomyopathy (PPCM) can lead to long-term systolic dysfunction, especially among black women. Hypertensive disorders of pregnancy (HDP) are the strongest risk factor for PPCM, but controversy remains on whether HDP predict a favorable outcome. Women with HDP are also often diagnosed with PPCM earlier than those without HDP. Our objective is to determine recovery of systolic function in patients with PPCM stratified by HDP, timing of diagnosis, and race. We conducted a retrospective cohort study of 220 patients (55% black) diagnosed with PPCM. Patients with PPCM and HDP were diagnosed earlier postpartum than patients without HDP (=0.013), an effect that was most pronounced in nonblack patients. Rates of left ventricular ejection fraction (LVEF) recovery were similar among PPCM patients with and without HDP (68.4% versus 62.6%, =0.425). In contrast, patients with PPCM diagnosed after 1-month postpartum had lower rates of LVEF recovery than patients diagnosed <1-month postpartum (53.7% versus 69.9%, =0.035). LVEF at time of diagnosis is a strong predictor of LVEF recovery, and patients with PPCM diagnosed after 1-month postpartum had lower baseline LVEF compared to patients presenting earlier (=0.041). The presence of HDP does not correlate with LVEF recovery in our racially diverse PPCM cohort. In contrast, early diagnosis portends a favorable outcome. Early diagnosis is associated with higher LVEF at presentation, likely explaining the improved outcomes in these women. These findings underscore the need for early monitoring and diagnosis, especially in at-risk and underserved populations.
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Peripartum Cardiomyopathy: Is It All in the Timing?
Hypertension2019 Nov;():HYPERTENSIONAHA11913742. doi: 10.1161/HYPERTENSIONAHA.119.13742.
Roth Flach Rachel J, Khankin Eliyahu V,
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Treatment of cardiogenic shock in peripartum cardiomyopathy: Case series from a tertiary ECMO center.
J Card Surg2019 Nov;():. doi: 10.1111/jocs.14324.
Djordjevic Ilija, Rahmanian Parwis, Zeriouh Mohamed, Eghbalzadeh Kaveh, Sangsari Sassan, Merkle Julia, Kuhn Elmar, Deppe Antje-Christin, Weber Carolyn, Sabashnikov Anton, Liakopoulos Oliver, Wahlers Thorsten,
Abstract
Peripartum cardiomyopathy (PPCM) occurs toward the end of pregnancy or in the months after delivery without previously known structural heart disease. Development of therapy-refractory cardiogenic shock is described in the literature with a limited number of overall presented cases in this young patient cohort. To provide differences and key points in the therapy of end-stage PPCM patients, we present a case series of four young women with PPCM referred to our department for potential VA ECMO support.
© 2019 Wiley Periodicals, Inc.
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Clinical features differentiating Takotsubo cardiomyopathy in the peripartum period from peripartum cardiomyopathy.
Heart Vessels2019 Nov;():. doi: 10.1007/s00380-019-01537-4.
Yang Woo-In, Moon Jae Youn, Shim Minjung, Yang Pil-Sung, Kang Se Hun, Kim Sang-Hoon, Kim Won-Jang, Sung Jung-Hoon, Kim In Jai, Lim Sang-Wook, Cha Dong-Hun, Ha Jong-Won,
Abstract
There are some similarities in clinical features between Takotsubo cardiomyopathy during the peripartum period (PTCM) and peripartum cardiomyopathy (PPCM). Both conditions present as acute heart failure and decreased left ventricular (LV) ejection fraction in the peripartum period in previously heart-healthy women. The present study aimed to evaluate the differences in clinical features and outcomes between PTCM and PPCM. Between January 2004 and December 2016, 37 consecutive patients who demonstrated LV dysfunction during the peripartum period without previous heart disease were recruited retrospectively. The clinical, laboratory, and echocardiographic data of these patients were comprehensively reviewed. Twenty-one (57%) and 16 (43%) patients were classified into PPCM and PTCM groups, respectively, based on echocardiographic findings. The initial LV ejection fraction did not differ significantly between the 2 groups. However, all patients with PTCM showed complete recovery of LV ejection fraction at the 1-month follow-up. However, among 20 patients with PPCM who underwent 1-month echocardiography, only 6 (30%) showed complete recovery of LV ejection fraction at the 1-month follow-up. At the 12-month follow-up, only 10 patients showed complete recovery of LV ejection fraction. The incidence of PTCM was much higher than expected. Although LV dysfunction was similar at the initial diagnosis, the prognosis of LV recovery was more favorable in PTCM than in PPCM. Therefore, physicians should differentiate these two diseases entities, although they have several similarities in acute LV dysfunction.
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Peripartum cardiomyopathy: disease or syndrome?
Heart2019 Mar;105(5):357-362. doi: 10.1136/heartjnl-2018-314252.
Baris Lucia, Cornette Jérôme, Johnson Mark R, Sliwa Karen, Roos-Hesselink Jolien W,
Abstract
Peripartum cardiomyopathy (PPCM) is a rare form of pregnancy-associated heart failure and is considered to be a diagnosis of exclusion. There are many hypotheses on the aetiology of PPCM; however, the exact pathophysiological mechanism remains unknown. It shows many resemblances to other conditions, such as familial dilated cardiomyopathy or myocarditis, and therefore it can be hard to make a definite diagnosis. We describe four cases of peripartum-onset heart failure in women who were suspected of having PPCM. We discuss the differential diagnosis, pathophysiological mechanisms and various diagnostic modalities.
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.
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Keeping up to date: a current review of wearable cardioverter defibrillator use.
Acta Cardiol2019 Nov;():1-10. doi: 10.1080/00015385.2019.1682337.
Ashraf Said, Ilyas Suleman, Siddiqui Fayez, Ando Tomo, Shokr Mohamed, Panaich Sidakpal, Briasoulis Alexandros, Afonso Luis, Khan Mazhar,
Abstract
The introduction of wearable cardioverter defibrillators (WCD) provides a novel means of protection in select patients at high risk for sudden cardiac death. The WCD can safely record and terminate life-threatening arrhythmias. In this review, we explore the data behind indications for WCD use and discuss its limitations. We searched PubMed, Google Scholar and Cochrane Central Register of controlled trials for relevant studies. The VEST trial, the first randomised controlled trial on WCD use, did not show statistical significance in utility of the WCD in post-myocardial infarction patients with low ejection fraction. While the use of WCD in this select patient population showed no benefit, the findings of the trial merit closer inspection. Various other indications of WCD use still exist and others require exploration. Select subsets of patients who stand to benefit for other indications include severely decreased left ventricular function post-revascularization with high arrhythmic burden, severe non-ischaemic cardiomyopathy, patients awaiting heart transplant and patients who have had their implantable cardioverter device temporarily removed. The role of the WCD is also being explored in children, peripartum cardiomyopathy, haemodialysis patients, and in syncope secondary to high-risk arrhythmias.
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Deficiency of Cardiac Natriuretic Peptide Signaling Promotes Peripartum Cardiomyopathy-Like Remodeling in the Mouse Heart.
Circulation2019 Oct;():. doi: 10.1161/CIRCULATIONAHA.119.039761.
Otani Kentaro, Tokudome Takeshi, Kamiya Chizuko A, Mao Yuanjie, Nishimura Hirohito, Hasegawa Takeshi, Arai Yuji, Kaneko Mari, Shioi Go, Ishida Junji, Fukamizu Akiyoshi, Osaki Tsukasa, Nagai-Okatani Chiaki, Minamino Naoto, Ensho Takuya, Hino Jun, Murata Shunsuke, Takegami Misa, Nishimura Kunihiro, Kishimoto Ichiro, Miyazato Mikiya, Harada-Shiba Mariko, Yoshimatsu Jun, Nakao Kazuwa, Ikeda Tomoaki, Kangawa Kenji,
Abstract
The maternal circulatory system and hormone balance both change dynamically during pregnancy, delivery, and the postpartum period. Although atrial and brain natriuretic peptides (ANP and BNP, respectively) produced in the heart control circulatory homeostasis through their common receptor, NPR1, the physiological and pathophysiological roles of endogenous ANP/BNP in the perinatal period are not fully understood. To clarify the physiological and pathophysiological roles of the endogenous ANP/BNP-NPR1 system during the perinatal period, the phenotype of female wild-type and conventional or tissue-specific Npr1-knockout mice during the perinatal period was examined, especially focusing on maternal heart weight, blood pressure, and cardiac function. In wild-type mice, lactation but not pregnancy induced reversible cardiac hypertrophy accompanied by increases in fetal cardiac gene mRNAs and ERK1/2 phosphorylation. Npr1-knockout mice exhibited significantly higher plasma aldosterone level than did wild-type mice, severe cardiac hypertrophy accompanied by fibrosis, and left ventricular dysfunction in the lactation period. In addition, Npr1-knockout mice showed a high mortality rate over consecutive pregnancy-lactation cycles. In the hearts of Npr1-knockout mice during or after the lactation period, an increase in interleukin-6 mRNA expression, phosphorylation of signal transducer and activator of transcription 3, and activation of the calcineurin-nuclear factor of activated T cells pathway were observed. Pharmacological inhibition of the mineralocorticoid receptor or neuron-specific deletion of the mineralocorticoid receptor gene significantly ameliorated cardiac hypertrophy in lactating Npr1-knockout mice. Anti-interleukin-6 receptor antibody administration tended to reduce cardiac hypertrophy in lactating Npr1-knockout mice. These results suggest that the characteristics of lactation-induced cardiac hypertrophy in wild-type mice are different from exercise-induced cardiac hypertrophy, and that the endogenous ANP/BNP-NPR1 system plays an important role in protecting the maternal heart from interleukin-6-induced inflammation and remodeling in the lactation period, a condition mimicking peripartum cardiomyopathy.
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1.5 CE Test Hours: Gestational Hypertension, Preeclampsia, and Peripartum Cardiomyopathy: A Clinical Review.
Am J Nurs -
CE: Gestational Hypertension, Preeclampsia, and Peripartum Cardiomyopathy: A Clinical Review.
Am J Nurs2019 Nov;119(11):32-40. doi: 10.1097/01.NAJ.0000605352.84144.a2.
Maheu-Cadotte Marc-André, Pépin Catherine, Lavallée Andréane, Hupé Catherine, Mailhot Tanya, Duchaine Caroline, Fontaine Guillaume,
Abstract
Gestational hypertension, preeclampsia, and peripartum cardiomyopathy are among the most common and often severe pregnancy-specific cardiovascular diseases (CVDs) and causes of complications in pregnancy. This clinical review provides nurses with an overview of pregnancy-specific CVDs, outlines their pathophysiology, and discusses risk factors and assessment. It describes management interventions according to timing: the antepartum, intrapartum, and postpartum phases are each addressed.
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Assisted reproductive technologies and metabolic syndrome complications: medico-legal reappraisal.
Clin Ter;170(5):e364-e367. doi: 10.7417/CT.2019.2161.
Baldini D, Beck R, Negro F, De Viti D,
Abstract
In the last 40 years, the number of elderly patients that require Assisted Reproductive Technologies (ART) has risen enormously, especially after heterolougus fertilization techniques have become available. In recent years, the incidence of peripartum cardiomyopathy (PPCM) has substantially grown, as a consequence of the combined effect of increased maternal age, consequent high prevalence of hypertension and metabolic syndrome (MS). That cohort of women may be exposed to a greater number of cardiac, obstetric and anesthesio-logical complications, therefore the incidence of medico-legal issues, litigation, liabilities and claims over the past years has significantly risen. Cardiovascular and hormonal changes during pregnancy can challenge even the healthiest of individuals, and in that pregnant population the risk is even greater. These patients should be monitored before the ART, during pregnancy, delivery and puerperium, to avoid heart failure, thrombotic problems, embolic complications, stroke and death. Management issues regarding pregnancy and delivery are elaborate, including anesthesia considerations. This new population of women needs an accurate cardiac risk stratification with a thorough cardiovascular history and examination, 12 lead ECG, and transthoracic echocardiogram. Therefore, a comprehensive multidisciplinary assessment and management can provide the best opportunity to improve maternal and neonatal outcomes.
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Peripartum cardiomyopathy: basic mechanisms and hope for new therapies.
Cardiovasc Res2019 Oct;():. doi: cvz252.
Ricke-Hoch Melanie, Pfeffer Tobias J, Hilfiker-Kleiner Denise,
Abstract
Peripartum cardiomyopathy (PPCM) is a life-threatening cardiomyopathy characterized by acute or slow progression of left ventricular (LV) systolic dysfunction (LV ejection fraction of <45%) late in pregnancy, during delivery, or in the first postpartum months, in women with no other identifiable causes of heart failure. PPCM patients display variable phenotypes and risk factor profiles, pointing to involvement of multiple mechanisms in the pathogenesis of the disease. The higher risk for PPCM in women with African ancestry, the prevalence of gene variants associated with cardiomyopathies, and the high variability in onset and disease progression in PPCM patients also indicate multiple mechanisms at work. Experimental data have shown that different factors can induce and drive PPCM, including inflammation and immunity, pregnancy hormone impairment, catecholamine stress, defective cAMP-PKA, and G-protein-coupled-receptor signalling, and genetic variants. However, several of these mechanisms may merge into a common major pathway, which includes unbalanced oxidative stress and the cleavage of the nursing hormone prolactin (PRL) into an angiostatic, pro-apoptotic, and pro-inflammatory 16?kDa-PRL fragment, resulting in subsequent vascular damage and heart failure. Based on this common pathway, potential disease-specific biomarkers and therapies have emerged. Despite commonalities, the variation in aetiology and mechanisms poses challenges for the diagnosis, treatment, and management of the disease. This review summarizes current knowledge on the clinical presentation of PPCM in the context of recent experimental research. It discusses the challenge to develop disease-specific biomarkers in the context of rapid changing physiology in the peripartum phase, and outlines possible future treatment and management strategies for PPCM patients.
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.
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Fragmented QRS as a candidate marker for left ventricular nonrecovery in patients with peripartum cardiomyopathy.
Ann Noninvasive Electrocardiol2019 Oct;():e12708. doi: 10.1111/anec.12708.
Tekin Tak Bahar, Cay Serkan, Ekizler Firdevs Aysenur, Ozcan Cetin Elif Hande, Pamukcu Hilal Erken, Kafes Habibe, Ulvan Nedret, Ozeke Ozcan, Ozcan Firat, Topaloglu Serkan, Aras Dursun,
Abstract
BACKGROUND:
Fragmented QRS (fQRS) complex, with various morphology, has been recently described as a diagnostic criterion of several cardiac diseases. However, there are little data regarding the prognostic role of fQRS in peripartum cardiomyopathy (PPCM) patients. We aimed to investigate the effect of fQRS on predicting left ventricular (LV) nonrecovery in patients with peripartum cardiomyopathy (PPCM).
METHODS:
Ninety patients (mean age: 34.7 ± 6.5 years) with the diagnosis of PPCM were analyzed retrospectively. The median follow-up period of was 67.0 (12.0-192.0) months. Fragmented QRS was defined as the presence of various RSR' patterns (QRS duration < 120 ms) with or without Q wave, which include an additional R wave (R' prime) or notching of the R wave or S wave, or the presence of more than one R' (fragmentation) without typical bundle branch block. Recovery of LV function was defined as the presence of LV ejection fraction (EF) >45%.
RESULTS:
Of the patients, 54 (60%) did not recover LV function at the last follow-up visit (nonrecovery group), while 36 of the patients (40%) exhibited LV recovery (recovery group). LV ejection fraction (EF) and fQRS were identified as independent predictors of LV nonrecovery in patients with PPCM (odds ratio OR: 5.546, 95% confidence interval CI: 0.792-0.979, p = .019 and OR: 5.986, 95% CI: 1.313-11.787, p = .014, respectively).
CONCLUSION:
Our data firstly indicated that presence of fQRS was a significant predictor of LV nonrecovery in patients with PPCM. The fQRS might assist in identifying high-risk patients.
© 2019 The Authors. Annals of Noninvasive Electrocardiology published by Wiley Periodicals, Inc.
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Cardiovascular Outcomes in Advanced Maternal Age Delivering Women. Clinical Review and Medico-Legal Issues.
Medicina (Kaunas)2019 Sep;55(10):. doi: E658.
De Viti Daniele, Malvasi Antonio, Busardò Francesco, Beck Renata, Zaami Simona, Marinelli Enrico,
Abstract
: Adverse cardiovascular outcomes during pregnancy have increased over the past few decades, with increased numbers of women delivering later in their reproductive life. Other factors include higher rates of female obesity, diabetes, hypertension, cardiovascular diseases and assisted reproductive technology, which has extended fertility. Those at risk require extensive prenatal maternal screening, constant pregnancy supervising, monitoring during labor, delivery and puerperium and careful anesthetic evaluation during delivery. : The present review reports the relevant information available on cardiovascular outcomes in advanced maternal age delivering women and related medico-legal issues. The search was performed on Pubmed, Cochrane, Semantic Scholar, Medline and Embase databases, accessed by Ovid, including among others the terms "cardiomyopathy", "ischaemic heart disease", "arrhythmias", "hypertension", "peripartum period", "diabetes", "advanced maternal age" "anesthesia", "maternal morbidity and mortality" and "litigation". : To the extent that underestimating risk factors for peripartum cardiomyopathy (PPCM) can adversely impact maternal and fetal outcomes, the legal implications of misdiagnosis or mismanagement can result in high compensatory damages. Substantial indemnity payments drive up costs of insurance coverage. : Multidisciplinary approaches are necessary from obstetricians, cardiologists, anesthesiologists and perinatologists for pregnancy monitoring and delivery outcomes.
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Global Left Ventricular Strain at Presentation Is Associated with Subsequent Recovery in Patients with Peripartum Cardiomyopathy.
J Am Soc Echocardiogr2019 Sep;():. doi: S0894-7317(19)30876-4.
Sugahara Masataka, Kagiyama Nobuyuki, Hasselberg Nina E, Blauwet Lori A, Briller Joan, Cooper Leslie, Fett James D, Hsich Eileen, Wells Gretchen, McNamara Dennis, Gorcsan John, ,
Abstract
BACKGROUND:
Peripartum cardiomyopathy (PPCM) is a serious complication of pregnancy associated with variable degrees of left ventricular (LV) recovery. The aim of this study was to test the hypothesis that global LV strain at presentation has prognostic value in patients with PPCM.
METHODS:
One hundred patients with PPCM aged 30 ± 6 years were enrolled in the multicenter Investigation in Pregnancy Associated Cardiomyopathy study along with 21 normal female control subjects. Speckle-tracking global longitudinal strain (GLS) and global circumferential strain (GCS) analysis was performed. The predefined primary combined outcome variable was death, transplantation, LV assist device implantation, or evidence of persistent LV dysfunction (LV ejection fraction [LVEF] < 50%) at 1 year.
RESULTS:
GLS measurement was feasible in 110 subjects: 89 of 90 patients with PPCM (99%) with echocardiographic data and all 21 control subjects. Of 84 patients (94%) with 1-year follow-up, 21 (25%) had unfavorable primary outcomes: four LV assist device placements, two deaths, and 15 patients with persistent LV dysfunction. GLS at presentation with a cutoff of 10.6% (absolute value) was specifically associated with the subsequent primary outcome with 75% sensitivity and 95% specificity. GCS at presentation with a cutoff of 10.1% was associated with the primary outcome with 78% sensitivity and 84% specificity. GLS and GCS remained significantly associated with outcomes after adjusting for LVEF (GLS odds ratio, 2.07; P < .001; GCS odds ratio, 1.37; P = .005). GLS was significantly additive to LVEF (C statistic = 0.76-0.91, net reclassification improvement = 1.32, P < .001).
CONCLUSIONS:
GLS and GCS in patients with PPCM at presentation were associated with subsequent clinical outcomes, including death, LV assist device implantation, and evidence of persistent LV dysfunction. Strain measures may add prognostic information over LVEF for risk stratification.
Copyright © 2019 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.
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Peripartum Cardiomyopathy: A Review.
Curr Emerg Hosp Med Rep2019 Sep;7(3):127-134. doi: 10.1007/s40138-019-00192-3.
Ballard Lindsay C, Cois Adrian, Kea Bory,
Abstract
Purpose of review:
Peripartum cardiomyopathy (PPCM) is an important condition with high morbidity and mortality worldwide. Patients with PPCM are at risk of developing life-long cardiac disease, requiring regular management and medical intervention. This article conducts a review of recent literature and gives insight into this disease.
Recent findings:
There is promising research in the fields of vascular, hormonal and genetics. A number of genetic markers are being analyzed; including TTNC1, TTN and STAT3. Mutations to these genes have been found to be prevalent in PPCM. These combined with the secretion of placental angiogenic factors potentially create imbalance in angiogenesis as the primary etiology.
Summary:
Current biomarkers do not differentiate between PPCM and other variants of heart failure. Women with PPCM are more likely to have a cesarean section, have hypertensive disease, at greater risk of major adverse cardiac events and to have lifelong morbidity.
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Prophylactic percutaneous left ventricular assist device in pregnancy.
Obstet Med2019 Sep;12(3):151-152. doi: 10.1177/1753495X18777346.
Westcott Jill M, Yaghoubian Yasaman, Williams Mathew R, Roman Ashley S, Hughes Francine, Rosner Mara,
Abstract
Pregnancy-associated cardiomyopathy can present earlier in gestation than traditionally defined peripartum cardiomyopathy. Management and optimal delivery timing for these patients are not well defined. We present the case of a 30-year-old primigravid at 26 weeks who presented with new onset ventricular tachycardia, biventricular cardiac failure, and severe mitral regurgitation. She was medically stabilized for two weeks prior to delivery with modest improvement in her condition. Due to concern for life-threatening cardiac failure and pulmonary edema at the time of delivery, a percutaneous left ventricular assist device was inserted immediately prior to cesarean delivery. She remained on mechanical circulatory support for 36 h. We discuss considerations regarding use of a percutaneous left ventricular assist device as a novel therapy to support the hemodynamic changes following delivery in parturients with decompensated heart failure.
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