Women with peripartum cardiomyopathy have normal ejection fraction, but abnormal systolic strain, during pregnancy

Abstract

We report a case series of six women with peripartum cardiomyopathy (PPCM) who incidentally underwent echocardiography prior to the clinical presentation of PPCM. For comparison, we identified controls, matched 2:1 on age, race, body mass index, gestational age, and hypertensive disorder. Among the six cases, all were diagnosed with PPCM during the post-partum period. Pre-PPCM echocardiograms were performed between 17.7 weeks of gestation and 13 days post-partum. Baseline left ventricular ejection fraction and size were normal and similar to the 12 matched controls (60% ± 6.6% vs. 61.4% ± 6.3%, P = 0.63) or left ventricular end-diastolic dimension (4.6 cm ± 0.2 cm vs. 4.5 cm ± 0.4 cm, P = 0.689). There was a trend towards a less negative (more abnormal) mean global longitudinal strain in cases compared with controls (À14% ± 4% vs. À18.3% ± 4.5%, P = 0.0658). Mean global circumferential strain was significantly less negative (more abnormal) in cases compared with controls (À21.5% ± 5% vs. À29.3% ± 7.6%, P = 0.0329). We conclude that women who develop PPCM have normal left ventricular ejection fraction during gestation preceding PPCM, indicating that the disease develops acutely in the peripartum period. Abnormal strain can be detected, however, suggesting that strain imaging could represent a screening method in populations at high risk for PPCM if confirmed in future studies.

Dyspnea in pregnancy might be related to the incomplete physiological adaptation of the heart

“… 19 Among these strain values, GCS index is a sensitive parameter for regional myocardial function. Tamrat et al 20 reported a significant fall in GCS among pregnant women with peripartum cardiomyopathy in spite of normal ejection fraction and left ventricular end-diastolic diameter. Additionally, GLS exhibited a drop in comparison with controls, but this reduction was nonsignificant.…”

Animal Models of Cardiovascular Complications of Pregnancy

“…First, the transgenic expression of Gαq was supraphysiologic, raising the possibility that the observed mechanism of cardiomyopathy is not relevant to human disease (transgenic lines with less induction of Gαq expression revealed no phenotype). Second, the transgenic mice revealed significant systolic dysfunction at baseline, even in the absence of pregnancy, whereas such dysfunction is not seen in women with PPCM, 139 and indeed the absence of such preexisting dysfunction is included in the definition of PPCM. This model was thus important as a first demonstration that pregnancy could accelerate cardiomyopathy in mice, but the model has not been used further.…”

Postpartum maternal tachycardia – diagnostic pitfalls!

“…It can assess for complications of PPCM such as left ventricular thrombus and provide prognostic data [19 ▪ ]. However, it should be noted that LVEF and LV dimensions are largely normal during pregnancy in women who go on to develop PPCM and these changes can occur acutely or shortly after diagnosis [21 ▪▪ ]. On echo, LVEF <30% at diagnosis leads to worse prognosis, reduced rates of recovery and increased risk of adverse effects [3,20 ▪▪ ].…”

“…Tamrat et al [21 ▪▪ ] suggest trying to assess for subclinical dysfunction using LV strain in a similar method to how LV dysfunction is assessed in the presence of cardiotoxic chemotherapy. They looked at global longitudinal strain (GLS) and global circumferential strain (GCS) and found that these measurements were able to identify subclinical dysfunction prior to the development of LV dysfunction and symptomatic HF, but that further work will need to be done to use it as a screening tool.…”