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Peripartum Cardiomyopathy requiring LVAD complicated by Embolic Stroke
Abstract Number: RF1AA-101
Abstract Type: Case Report Case Series
The incidence of peripartum cardiomyopathy (PPCM) has increased (1), as well as in-hospital mortality rates from PPCM despite an increased utilization of mechanical circulatory support (MCS)(2). MCS is not a benign intervention; complications can include bleeding, thrombosis, infection, or stroke (3). We report a case of severe PPCM treated with MCS complicated by significant morbidity.
A previously healthy 36-year-old woman with an uncomplicated pregnancy presented to a community hospital 3 months postpartum with dyspnea on exertion and orthopnea. She was treated for an upper respiratory infection with no improvement of her symptoms. An echocardiogram was performed and showed dilated LV with EF 20%. Heart failure therapy was started with lisinopril, carvedilol, spironolactone, and furosemide. She became dyspneic with minimal activity and hypotensive, and she was transferred to our center. On arrival, right heart catheterization evidenced cardiogenic shock (elevated R-sided filling pressures, severely elevated L-sided filling pressures, reduced CO and EF 11%). Neurological and renal function were preserved. PPCM was diagnosed. Decision was made to place R- and L-sided Impella devices. The procedure was uneventful, and heparin infusion was started. On POD1, she was found to have L-sided hemiplegia. CT/CTA demonstrated acute dissection of the right internal carotid artery with no ICA filling and M1 segment occlusion concerning for subacute MCA stroke. She was not a candidate for tPA or embolectomy. Craniotomy was not performed due to improving neurological status. R-sided Impella was weaned on POD4. L-sided Impella remained until POD20. She was then transitioned to a Heartmate3 LVAD. Intraoperatively she presented complete heart block and asystole requiring chest reopening, cardiac massage, and placement of a transvenous pacer. Anticoagulation was started with heparin infusion and transitioned to warfarin. On POD39 she had two syncopal episodes. Head CT revealed hemorrhagic conversion. Her anticoagulation was held and reversed. Follow-up imaging revealed no further hemorrhage. Low dose heparin infusion was restarted with serial neurological examination. Patient was transitioned to low dose LMWH. She was transferred to rehabilitation, discharged home, remained LVAD-dependent, and listed for heart transplant.
Most cases of PPCM occur during the first weeks after delivery. The late yet catastrophic presentation in our patient highlights the need for a low index-of-suspicion regarding PPCM. A low ejection fraction predicts worse outcomes (4), including need for transplantation, and the use of MCS as bridge therapy can have critical adverse effects and complications.
1. Mielniczuk LM et al. Am J Cardiol. 2006 Jun 15;97(12):1765-8
2. Kolte D et al. J Am Heart Assoc. 2014 Jun 4;3(3):e001056
3. Terzi A. Int J Artif Organs. 2019 Jan 8:391398818822267
4. Goland, et al. J Card Fail 2009;15:645-50