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Management of Peripartum Cardiomyopathy: A Case Report
Abstract Number: RF2AB-209
Abstract Type: Case Report Case Series
Introduction: Peripartum cardiomyopathy (PPCM) is a cause of pregnancy-associated heart failure. It typically develops during the last month of, and up to 6 months after pregnancy in women without known cardiovascular disease.
Case Report: Preop: LR was a 41 year old female at 36w3d gestation, presenting for elective C-section (repeat X1). Patient presented with shortness of breath for 2 days, lower and upper extremity swelling (2 months), and shortness of breath when lying flat. Patient was seen and evaluated by cardiology. Echo and EKG were performed and showed sinus tachycardia with HR up to 140s, global cardiomopathy, and EF of 21-25%. Troponin 0.09. BNP 528. Multidisciplinary meeting held with OB, Cardiology, and Cardiac anesthesiology teams in attendance.
Intraop: C/S under GA because patient would not tolerate lying supine for prolonged period. Intraop TEE showed EF of 10-15% with large bilateral pleural effusions. APGAR at 1 min and 5 min were 1 and 8 respectively. Post-op TEE showed EF of 20%. Patient failed trial of extubation with desaturation on pulse oximetry and ABG showing low pO2 and retained pCO2. Patient taken to CICU for post-op management.
Postop: LR had a tumultuous course in the ICU with prolonged intubation, recurrent desaturations, hypotension, development of a septic picture, renal failure, and questionable preeclampsia. About 2 weeks after delivery, an IABP was placed and about a month after delivery an Impella device was placed for continued cardiogenic shock. EF improved after Impella device. A week later, Impella was removed and EF was again 20%. Decision was made to place LVAD and Heartmate 3 was placed. Patient was discharged to rehab shortly thereafter.
Discussion: Pathophysiology of PPCM is poorly understood. Current theories include development of myocarditis, abnormal immune response to pregnancy, and a pathological response to the hemodynamic stresses of pregnancy. Treatment is usually supportive since about 50% of women have return of baseline LV function by 6 months to 5 years. Mechanical circulatory support may be required for "bridge" or "destination" therapy," and outcomes in these cases are generally positive. PPCM patients who require heart transplants tend to have worse outcomes than other cardiac transplant patients.
Sliwa, Karen, et al. “Current State of Knowledge on Aetiology, Diagnosis, Management, and Therapy of Peripartum Cardiomyopathy: a Position Statement from the Heart Failure Association of the European Society of Cardiology Working Group on Peripartum Cardiomyopathy.” European Journal of Heart Failure, vol. 12, no. 8, 2010, pp. 767–778., doi:10.1093/eurjhf/hfq120.
Fett, James D., et al. “Five-Year Prospective Study of the Incidence and Prognosis of Peripartum Cardiomyopathy at a Single Institution.” Mayo Clinic Proceedings, vol. 80, no. 12, 2005, pp. 1602–1606., doi:10.4065/80.12.1602.