Peripartum cardiomyopathy with biventricular thrombus which led to massive cerebral embolism

Abstract

A 37-year-old female who delivered her second child via a cesarean section 4 months previously presented to our hospital with gradual worsening of dyspnea on effort. Chest radiographic appearance showed cardiomegaly (cardiothoracic ratio 61%) and slight bilateral pulmonary congestion. Echocardiogram revealed diffuse hypokinesis of both left and right ventricles (left ventricular ejection fraction 29%) and large biventricular thrombus [left ventricular apex (28 mm × 21 mm, 22 mm × 14 mm) and right ventricular apex (16 mm × 11 mm)]. She was diagnosed as having peripartum cardiomyopathy (PPCM) and anticoagulation therapy was started. Surgical thrombectomy was not selected because of risk of complications. Massive cerebral infarction occurred 10 days after diagnosis. She was discharged with aphasia and right incomplete hemiplegia 65 days after admission.Biventricular thrombus is a rare complication of PPCM. If high risk of massive embolism is considered, surgical thrombectomy may be warranted even in cases with low cardiac function. <Learning objective: Biventricular thrombus is a rare complication of peripartum cardiomyopathy (PPCM). We report a case of biventricular thrombus secondary to PPCM. The decision to perform prophylactic surgical approach to ventricular thrombus is difficult in cases with low cardiac function.>

Anticoagulation for intra-cardiac thrombi in peripartum cardiomyopathy: A review of the literature

“…The age of women in our study ranged from 20-38 years, mean of 28.1 years. Table. 1 describe all the included case reports (Altuwaijri et al, 2012;Bagul et al, 2014;Bhat et al, 1986;Box et al, 2004;Corriveau et al, 2014;Ibebuogu et al, 2007;Kaufman et al, 2003;Kharwar et al, 2014;Kim et al, 2011;Nishi et al, 2002;Sakamoto et al, 2013;Shimamoto et al, 2008).…”

Risk factors and outcomes associated with Left Ventricular Thrombus in patients with Peripartum Cardiomyopathy: An insight from National Inpatient Sample Database

“…Additionally, the percentage of patients with PPCM both with and without LV thrombus was significantly higher in urban hospitals compared to rural settings Table 1 . Overall, this suggests an underestimation or underreporting of the true incidence of PPCM as well as LV thrombus, especially in rural settings, possibly due to lack of awareness, expertise, misdiagnosis or population demographics [ 2 , 8 ]. Furthermore, a review of prior studies on cardiac imaging has revealed that up to two-thirds of LV thrombi can be missed by the routinely performed non-contrast echocardiography (ECHO), with mural or small thrombi least likely to be detected [13] .…”

“…The incidence of LV thrombus complicating PPCM in a single center study was reported to be as high as 17% [7] . Furthermore, several cases of left and right ventricular thrombi complicating peripartum cardiomyopathy have been reported [8] , [9] , [10] . These studies have shown favorable outcomes in these patients when appropriate treatment including anticoagulation is initiated in a timely manner.…”

A case of familial thrombophilia in the patient with complicated peripartum cardiomyopathy

“…PPCM genetic traits, such as association of genome to locus chromosome 12р11.22, the presence of nucleotide polymorphism rs258415, and gene mutations MYH7 and MYH6 [5], presumably are not related to defect characteristics seen in congenital thrombophilias (such as factor V Leiden mutation, prothrombin G20210A, etc.). Our literature search did not reveal evidential data on the genetic relationship between the PPCM and hemostasis abnormalities, such as congenital thrombophilia, thromboembolisms, intra-and extracardiac thromboses at peripartum cardiomyopathy [7,10]. However, our clinical observations provided below suggest …”