Right Ventricular Function in Peripartum Cardiomyopathy at Presentation Is Associated With Subsequent Left Ventricular Recovery and Clinical Outcomes

Abstract

P eripartum cardiomyopathy (PPCM) is a pregnancy-associated cardiomyopathy of unknown cause resulting in considerable morbidity and mortality in young, otherwise healthy women. The natural history of PPCM seems to be variable although the rarity of this disease and the inconsistent diagnostic criteria that have been used in previous case series and research studies make it difficult to accurately describe the range of disease progression. Retrospective studies of patients with PPCM in the United States have shown that mortality is as high as 18%, [1][2][3][4][5][6] and left ventricular (LV) ejection fraction (LVEF) returns to normal at 6 months to 1 year in only 40% to 62% of patients. 3,[6][7][8] See Clinical PerspectiveGiven the relatively high rates of death and persistent LV dysfunction in patients with PPCM, establishing reliable predictors of outcome is important to enable clinicians to provide optimal care for these patients. Previous retrospective studies have shown numerous factors to be associated with recovery of LV function, but none has been validated in a large prospective cohort and none has focused on right ventricular (RV) function. RV function at diagnosis has been shown to predict outcomes among patients with other types of acute cardiomyopathies, 9-14 so it seems reasonable to expect that RV function at baseline predicts LV recovery and cardiac events in patients with PPCM as well.The Investigations of Pregnancy-Associated Cardiomyopathy (IPAC) study was a multicenter prospective study of the demographics, inflammatory pathogenesis, treatment, and clinical predictors of outcome for patients with PPCM in North America.15 PPCM is a diffuse process that affects biventricular function to a variable degree, and we hypothesized that patients who manifest RV dysfunction at presentation Background-Peripartum cardiomyopathy has variable disease progression and left ventricular (LV) recovery. We hypothesized that baseline right ventricular (RV) size and function are associated with LV recovery and outcome. Methods and Results-Investigations of Pregnancy-Associated Cardiomyopathy was a prospective 30-center study of 100 peripartum cardiomyopathy women with LV ejection fraction (LVEF) <45% within 13 weeks after delivery. Baseline RV function was assessed by echocardiographic end-diastolic area, end-systolic area, fractional area change, tricuspid annular plane excursion, and RV speckle-tracking longitudinal strain. LV recovery was defined as LVEF of ≥50% at 1 year, persistent severe LV dysfunction as LVEF of ≤35%, and major events as death, transplant, or LV assist device implantation. RV measurements were feasible for 90 of the 96 patients (94%) with echocardiograms available. Mean baseline LVEF was 36±9%. RV fractional area change was <35% in 38% of patients. Of 84 patients with 1-year followup data, 63 (75%) had LV recovery and 11 (13%) had LVEF of ≤35% or a major event (4 LV assist devices and 2 deaths). Tricuspid annular plane excursion and RV strain did not predict outcome. Baseline RV fractional ...

Angiogenic Imbalance and Residual Myocardial Injury in Recovered Peripartum Cardiomyopathy Patients

“…Two studies have addressed the question of RV function in women with PPCM at presentation, one reporting tricuspid annular plane systolic excursion ≤14 mm in 54.6% of patients 34 and another describing the association of RV function with subsequent LV recovery at 1 year. 35 In our study, we found lower RV systolic velocities on TDI and longitudinal strain in patients with post-PPCM compared with controls, suggesting some subtle residual changes of the RV. Altered TDI and 2DS indices suggest residual myocardial injury in recovered post-PPCM patients with the so-called complete LV function recovery.…”

Myocardial remodelling and recovery in dilated cardiomyopathy

“…Right ventricular function at baseline has recently been shown to predict LV remodeling at follow up in peri-partum cardiomyopathy patients. 31 This remains unexplored in DCM.…”

Initial Right Ventricular Dysfunction Severity Identifies Severe Peripartum Cardiomyopathy Phenotype With Worse Early and Overall Outcomes: A 24‐Year Cohort Study

“…Only 3 prior studies have assessed the RV systolic function in PPCM outcomes. All were limited to 6 or 12 months' follow‐up . The IPAC (Investigations of Pregnancy Associated Cardiomyopathy) study, the largest of these multicenter studies, evaluated multiple quantitative echocardiographic indexes of baseline RV and LV size and function in association with LV recovery and clinical outcome at 1 year .…”

“…PPCM accounts for 5% of all women who undergo cardiac transplantation and 8% who undergo mechanical circulatory support device implantation in the United States . Despite the potential for late adverse outcomes, prior PPCM studies have largely focused on in‐hospital outcomes or those within the first year of diagnosis . Severe LV systolic dysfunction and LV dilatation have long been identified as major physiologic risk factors for adverse outcomes in PPCM .…”

“…Severe LV systolic dysfunction and LV dilatation have long been identified as major physiologic risk factors for adverse outcomes in PPCM . Right ventricular (RV) systolic function at presentation was recently identified as a strong independent predictor of LV recovery and clinical events at 1 year …”