Peripartum cardiomyopathy: modern management options for patients with severe heart failure

Main Article Content

Ya. M. Lutai
O. M. Parkhomenko
O. I. Irkin
A. V. Nemyrska

Abstract

Peripartum cardiomyopathy (PCMP) is a cardiomyopathy with impaired LV systolic function that develops in pregnant women or in the first months after childbirth. Clinical manifestations can vary from mild or moderate to severe symptoms of heart failure with significant functional limitation and high mortality. The mechanisms of PCMP development are unknown, and there is no specific treatment. In the article, we wanted to demonstrate our own experience of managing a patient with severe PCMP, the course of which was complicated by heart rhythm disturbances, the development of cardiogenic shock and pulmonary edema. This clinical example will highlight basic information about the etiology, pathogenesis, prevention and treatment of PCMP at the current stage. 

Article Details

Keywords:

peripartum cardiomyopathy, clinical case, diagnosis, treatment, levosimendan, bromocriptine, glucocorticoids

References

Bauersachs J, König T, van der Meer P, Petrie MC, Hilfiker-Kleiner D, Mbakwem A, Hamdan R, Jackson AM, Forsyth P, de Boer RA, Mueller C, Lyon AR, Lund LH, Piepoli MF, Heymans S, Chioncel O, Anker SD, Ponikowski P, Seferovic PM, Johnson MR, Mebazaa A, Sliwa K. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail. 2019 Jul;21(7):827-43. https://doi.org/10.1002/ejhf.1493.

Jackson AM, Macartney M, Brooksbank K, Brown C, Dawson D, Francis M, Japp A, Lennie V, Leslie SJ, Martin T, Neary P, Venkatasubramanian S, Vickers D, Weir RA, McMurray JJV, Jhund PS, Petrie MC. A 20-year population study of peripartum cardiomyopathy. Eur Heart J. 2023 Dec 21;44(48):5128-41. https://doi.org/10.1093/eurheartj/ehad626.

Kamiya CA, Kitakaze M, Ishibashi-Ueda H, Nakatani S, Murohara T, Tomoike H, Ikeda T. Different characteristics of peripartum cardiomyopathy between patients complicated with and without hypertensive disorders. Results from the Japanese Nationwide survey of peripartum cardiomyopathy. Circ J. 2011;75(8):1975-81. https://doi.org/10.1253/circj.cj-10-1214.

Isezuo SA, Abubakar SA. Epidemiologic profile of peripartum cardiomyopathy in a tertiary care hospital. Ethn Dis. 2007 Spring;17(2):228-33.

Fett JD, Christie LG, Carraway RD, Murphy JG. Five-year prospective study of the incidence and prognosis of peripartum cardiomyopathy at a single institution. Mayo Clin Proc. 2005 Dec;80(12):1602-6. https://doi.org/10.4065/80.12.1602.

Tseluiko VY, Boutko OO. Peripartum cardiomyopathy. Liky Ukrainy. 2019;8:47-52. doi: https://doi.org/10.37987/1997-9894.2019.8(234).187236. Ukrainian.

Rusnak ІТ, Tashchuk VK, Slyvka NO, Kulachek VT, Kulachek YV. Peripartum cardiomyopathy – a clinical case. Сlinical and experimental pathology. 2020;19(4):125-9. https://doi.org/10.24061/1727-4338.XIX.4.74.2020.19. Ukrainian.

Brar SS, Khan SS, Sandhu GK, Jorgensen MB, Parikh N, Hsu JW, Shen AY. Incidence, mortality, and racial differences in peripartum cardiomyopathy. Am J Cardiol. 2007 Jul 15;100(2):302-4. https://doi.org/10.1016/j.amjcard.2007.02.092.

Bello N, Rendon ISH, Arany Z. The relationship between pre-eclampsia and peripartum cardiomyopathy: a systematic review and meta-analysis. J Am Coll Cardiol. 2013 Oct 29;62(18):1715-23. https://doi.org/10.1016/j.jacc.2013.08.717.

Arany Z. Peripartum Cardiomyopathy. N Engl J Med. 2024 Jan 11;390(2):154-164. https://doi.org/10.1056/NEJMra2306667.

Davis MB, Jarvie J, Gambahaya E, Lindenfeld J, Kao D. Risk Prediction for Peripartum Cardiomyopathy in Delivering Mothers: A Validated Risk Model: PPCM Risk Prediction Model. J Card Fail. 2021 Feb;27(2):159-67. https://doi.org/10.1016/j.cardfail.2020.12.022.

Liu LX, Arany Z. Maternal cardiac metabolism in pregnancy. Cardiovasc Res. 2014 Mar 15;101(4):545-53. https://doi.org/10.1093/cvr/cvu009.

Fett JD, Ansari AA, Sundstrom JB, Combs GF. Peripartum cardiomyopathy: a selenium disconnection and an autoimmune connection. Int J Cardiol. 2002 Dec;86(2-3):311-6. https://doi.org/10.1016/s0167-5273(02)00359-5.

Fett JD. Viral infection as a possible trigger for the development of peripartum cardiomyopathy. Int J Gynaecol Obstet. 2007 May;97(2):149-50. https://doi.org/10.1016/j.ijgo.2007.01.012.

Halkein J, Tabruyn SP, Ricke-Hoch M, Haghikia A, Nguyen NQ, Scherr M, Castermans K, Malvaux L, Lambert V, Thiry M, Sliwa K, Noel A, Martial JA, Hilfiker-Kleiner D, Struman I. MicroRNA-146a is a therapeutic target and biomarker for peripartum cardiomyopathy. J Clin Invest. 2013 May;123(5):2143-54. https://doi.org/10.1172/JCI64365.

Damp J, Givertz MM, Semigran M, Alharethi R, Ewald G, Felker GM, Bozkurt B, Boehmer J, Haythe J, Skopicki H, Hanley-Yanez K, Pisarcik J, Halder I, Gorcsan J 3rd, Rana S, Arany Z, Fett JD, McNamara DM; IPAC Investigators. Relaxin-2 and Soluble Flt1 Levels in Peripartum Cardiomyopathy: Results of the Multicenter IPAC Study. JACC Heart Fail. 2016 May;4(5):380-8. https://doi.org/10.1016/j.jchf.2016.01.004.

Roh JD, Castro C, Yu A, Rana S, Shahul S, Gray KJ, Honigberg MC, Ricke-Hoch M, Iwamoto Y, Yeri A, Kitchen R, Guerra JB, Hobson R, Chaudhari V, Chang B, Sarma A, Lerchenmüller C, Al Sayed ZR, Diaz Verdugo C, Xia P, Skarbianskis N, Zeisel A, Bauersachs J, Kirkland JL, Karumanchi SA, Gorcsan J 3rd, Sugahara M, Damp J, Hanley-Yanez K, Ellinor PT, Arany Z, McNamara DM; IPAC Investigators; Hilfiker-Kleiner D, Rosenzweig A. Placental senescence pathophysiology is shared between peripartum cardiomyopathy and preeclampsia in mouse and human. Sci Transl Med. 2024 Apr 17;16(743):eadi0077. https://doi.org/10.1126/scitranslmed.adi0077.

Feridooni HA, MacDonald JK, Ghimire A, Pyle WG, Howlett SE. Acute exposure to progesterone attenuates cardiac contraction by modifying myofilament calcium sensitivity in the female mouse heart. Am J Physiol Heart Circ Physiol. 2017 Jan 1;312(1):H46-H59. https://doi.org/10.1152/ajpheart.00073.2016.

Goli R, Li J, Brandimarto J, Levine LD, Riis V, McAfee Q, DePalma S, Haghighi A, Seidman JG, Seidman CE, Jacoby D, Macones G, Judge DP, Rana S, Margulies KB, Cappola TP, Alharethi R, Damp J, Hsich E, Elkayam U, Sheppard R, Alexis JD, Boehmer J, Kamiya C, Gustafsson F, Damm P, Ersbøll AS, Goland S, Hilfiker-Kleiner D, McNamara DM; IMAC-2 and IPAC Investigators; Arany Z. Genetic and Phenotypic Landscape of Peripartum Cardiomyopathy. Circulation. 2021 May 11;143(19):1852-62. https://doi.org/10.1161/CIRCULATIONAHA.120.052395.

Arany Z. It Is Time to Offer Genetic Testing to Women With Peripartum Cardiomyopathy. Circulation. 2022 Jul 5;146(1):4-5. https://doi.org/10.1161/CIRCULATIONAHA.122.059177.

Hu CL, Li YB, Zou YG, Zhang JM, Chen JB, Liu J, Tang YH, Tang QZ, Huang CX. Troponin T measurement can predict persistent left ventricular dysfunction in peripartum cardiomyopathy. Heart. 2007 Apr;93(4):488-90. https://doi.org/10.1136/hrt.2006.087387.

Hoevelmann J, Engel ME, Muller E, Hohlfeld A, Böhm M, Sliwa K, Viljoen C. A global perspective on the management and outcomes of peripartum cardiomyopathy: a systematic review and meta-analysis. Eur J Heart Fail. 2022 Sep;24(9):1719-36. https://doi.org/10.1002/ejhf.2603.

Amos AM, Jaber WA, Russell SD. Improved outcomes in peripartum cardiomyopathy with contemporary. Am Heart J. 2006 Sep;152(3):509-13. https://doi.org/10.1016/j.ahj.2006.02.008.

Haghikia A, Röntgen P, Vogel-Claussen J, Schwab J, Westenfeld R, Ehlermann P, Berliner D, Podewski E, Hilfiker-Kleiner D, Bauersachs J. Prognostic implication of right ventricular involvement in peripartum cardiomyopathy: a cardiovascular magnetic resonance study. ESC Heart Fail. 2015 Dec;2(4):139-49. https://doi.org/10.1002/ehf2.12059.

Davis EM, Ewald G, Givertz MM, Rajagopalan N, Cooper LT Jr, Briller J, Felker GM, Bozkurt B, Drazner MH, Hanley-Yanez K, Halder I, McTiernan CF, McNamara DM; IPAC Investigators. Maternal Obesity Affects Cardiac Remodeling and Recovery in Women with Peripartum Cardiomyopathy. Am J Perinatol. 2019 Apr;36(5):476-83. https://doi.org/10.1055/s-0038-1669439.

Goland S, Modi K, Hatamizadeh P, Elkayam U. Differences in clinical profile of African-American women with peripartum cardiomyopathy in the United States. J Card Fail. 2013 Apr;19(4):214-8. https://doi.org/10.1016/j.cardfail.2013.03.004.

Forster O, Hilfiker-Kleiner D, Ansari AA, Sundstrom JB, Libhaber E, Tshani W, Becker A, Yip A, Klein G, Sliwa K. Reversal of IFN-gamma, oxLDL and prolactin serum levels correlate with clinical improvement in patients with peripartum cardiomyopathy. Eur J Heart Fail. 2008 Sep;10(9):861-8. https://doi.org/10.1016/j.ejheart.2008.07.005.

Xu H, Zhao L, Fu H, Xu R, Xie L, Zhang K, Song Y, Yang Z, Zhao S, Guo Y. Prognostic Value of Cardiac MRI Late Gadolinium Enhancement in Patients with Peripartum Cardiomyopathy: A Retrospective Study. Curr Probl Cardiol. 2023 Apr;48(4):101587. https://doi.org/10.1016/j.cpcardiol.2023.101587.

McNamara DM, Elkayam U, Alharethi R, Damp J, Hsich E, Ewald G, Modi K, Alexis JD, Ramani GV, Semigran MJ, Haythe J, Markham DW, Marek J, Gorcsan J 3rd, Wu WC, Lin Y, Halder I, Pisarcik J, Cooper LT, Fett JD; IPAC Investigators. Clinical Outcomes for Peripartum Cardiomyopathy in North America: Results of the IPAC Study (Investigations of Pregnancy-Associated Cardiomyopathy). J Am Coll Cardiol. 2015 Aug 25;66(8):905-14. https://doi.org/10.1016/j.jacc.2015.06.1309.

Loyaga-Rendon RY, Pamboukian SV, Tallaj JA, Acharya D, Cantor R, Starling RC, Naftel D, Kirklin J. Outcomes of patients with peripartum cardiomyopathy who received mechanical circulatory support. Data from the Interagency Registry for Mechanically Assisted Circulatory Support. Circ Heart Fail. 2014 Mar 1;7(2):300-9. https://doi.org/10.1161/CIRCHEARTFAILURE.113.000721.

Stapel B, Kohlhaas M, Ricke-Hoch M, Haghikia A, Erschow S, Knuuti J, Silvola JM, Roivainen A, Saraste A, Nickel AG, Saar JA, Sieve I, Pietzsch S, Müller M, Bogeski I, Kappl R, Jauhiainen M, Thackeray JT, Scherr M, Bengel FM, Hagl C, Tudorache I, Bauersachs J, Maack C, Hilfiker-Kleiner D. Low STAT3 expression sensitizes to toxic effects of β-adrenergic receptor stimulation in peripartum cardiomyopathy. Eur Heart J. 2017 Feb 1;38(5):349-361. https://doi.org/10.1093/eurheartj/ehw086.

Papp Z, Édes I, Fruhwald S, De Hert SG, Salmenperä M, Leppikangas H, Mebazaa A, Landoni G, Grossini E, Caimmi P, Morelli A, Guarracino F, Schwinger RH, Meyer S, Algotsson L, Wikström BG, Jörgensen K, Filippatos G, Parissis JT, González MJ, Parkhomenko A, Yilmaz MB, Kivikko M, Pollesello P, Follath F. Levosimendan: molecular mechanisms and clinical implications: consensus of experts on the mechanisms of action of levosimendan. Int J Cardiol. 2012 Aug 23;159(2):82-7. https://doi.org/10.1016/j.ijcard.2011.07.022.

Biteker M, Duran NE, Kaya H, Gündüz S, Tanboğa HÎ, Gökdeniz T, Kahveci G, Akgün T, Yildiz M, Õzkan M. Effect of levosimendan and predictors of recovery in patients with peripartum cardiomyopathy, a randomized clinical trial. Clin Res Cardiol. 2011 Jul;100(7):571-7. https://doi.org/10.1007/s00392-010-0279-7.

Benlolo S, Lefoll C, Katchatouryan V, Payen D, Mebazaa A. Successful use of levosimendan in a patient with peripartum cardiomyopathy. Anesth Analg. 2004 Mar;98(3):822-4, table of contents. https://doi.org/10.1213/01.ane.0000099717.40471.83.

Nieto Estrada VH, Molano Franco DL, Valencia Moreno AA, Rojas Gambasica JA, Jaller Bornacelli YE, Martinez Del Valle A. Reversion of Severe Mitral Insufficiency in Peripartum Cardiomyopathy Using Levosimendan. J Clin Med Res. 2015 Dec;7(12):998-1001. https://doi.org/10.14740/jocmr2323w.

Kaur P, Kundra TS. Role of inhaled levosimendan in peripartum cardiomyopathy. Saudi J Anaesth. 2022 Oct-Dec;16(4):500-3. https://doi.org/10.4103/sja.sja_297_22.

Kundra TS, Nagaraja PS, Bharathi KS, Kaur P, Manjunatha N. Inhaled levosimendan versus intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement. Ann Card Anaesth. 2018 Jul-Sep;21(3):328-32. https://doi.org/10.4103/aca.ACA_19_18.

Sliwa K, Blauwet L, Tibazarwa K, Libhaber E, Smedema JP, Becker A, McMurray J, Yamac H, Labidi S, Struman I, Hilfiker-Kleiner D. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy: a proof-of-concept pilot study. Circulation. 2010 Apr 6;121(13):1465-73. https://doi.org/10.1161/CIRCULATIONAHA.109.901496.

Haghikia A, Podewski E, Libhaber E, Labidi S, Fischer D, Roentgen P, Tsikas D, Jordan J, Lichtinghagen R, von Kaisenberg CS, Struman I, Bovy N, Sliwa K, Bauersachs J, Hilfiker-Kleiner D. Phenotyping and outcome on contemporary management in a German cohort of patients with peripartum cardiomyopathy. Basic Res Cardiol. 2013 Jul;108(4):366. https://doi.org/10.1007/s00395-013-0366-9.

Hilfiker-Kleiner D, Haghikia A, Berliner D, Vogel-Claussen J, Schwab J, Franke A, Schwarzkopf M, Ehlermann P, Pfister R, Michels G, Westenfeld R, Stangl V, Kindermann I, Kühl U, Angermann CE, Schlitt A, Fischer D, Podewski E, Böhm M, Sliwa K, Bauersachs J. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study. Eur Heart J 2017;38:2671–2679. https://doi.org/10.1093/eurheartj/ ehx355.

Voors AA, Angermann CE, Teerlink JR, Collins SP, Kosiborod M, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Tromp J, Borleffs CJW, Ma C, Comin-Colet J, Fu M, Janssens SP, Kiss RG, Mentz RJ, Sakata Y, Schirmer H, Schou M, Schulze PC, Spinarova L, Volterrani M, Wranicz JK, Zeymer U, Zieroth S, Brueckmann M, Blatchford JP, Salsali A, Ponikowski P. The SGLT2 inhibitor empagliflozin in patients hospitalized for acute heart failure: a multinational randomized trial. Nat Med. 2022 Mar;28(3):568-74. https://doi.org/10.1038/s41591-021-01659-1.

Radakrishnan A, Dokko J, Pastena P, Kalogeropoulos AP. Thromboembolism in peripartum cardiomyopathy: a systematic review. J Thorac Dis. 2024 Jan 30;16(1):645-60. https://doi.org/10.21037/jtd-23-945.

Bozkurt B, Colvin M, Cook J, Cooper LT, Deswal A, Fonarow GC, Francis GS, Lenihan D, Lewis EF, McNamara DM, Pahl E, Vasan RS, Ramasubbu K, Rasmusson K, Towbin JA, Yancy C. Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association. Circulation. 2016 Dec 6;134(23):e579-e646. https://doi.org/10.1161/CIR.0000000000000455. Epub 2016 Nov 3. Erratum in: Circulation. 2016 Dec 6;134(23):e652. https://doi.org/10.1161/CIR.0000000000000474.

Basu J, Redman C, Ormerod O. Immunosuppression therapy in the management of peripartum cardiomyopathy: A case series and literature review. Obstet Med. 2016 Dec;9(4):174-176. https://doi.org/10.1177/1753495X16655915.

Most read articles by the same author(s)

1 2 3 > >>