Transcript PERIPARTUM CARDIOMYOPATHY

PERIPARTUM CARDIOMYOPATHY
Dr Amr Sobhy
M.D in anaesthesia and I.C.U
Lecturer in faculty of medicine ain shames university
Objectives
 Definition
 Epidemiology
 Diagnosis
 Management
 Update
 Prognosis
Definition
 An idiopathic cardiomyopathy presenting with
heart failure secondary to LV systolic
dysfunction towards the end of pregnancy or in
the months following delivery, where no other
cause of heart failure is found. It is a diagnosis of
exclusion. The LV may not be dilated but the
ejection fraction is nearly always reduced below
45%
Heart Failure Association of the ESC Working Group on PPCM (Sliwa et al., 2010)
Epidemiology
Incidence
 The incidence in the west ranges from 1 in
4000 deliveries
 60% present within the first 2 months
postpartum
 Up to 7% may present in the last trimester of
pregnancy.
 Geographic variations exist with a higher
incidence reported in areas of Africa .
Epidemiology
Etiology
Still unknown.
 Nutritional deficiencies
 Small vessel coronary artery abnormality
 Hormonal effects
 Toxemia
 Maternal immunologic response to fetal
antigen or myocarditis
Epidemiology
Predisposing factors
 Maternal age greater than 30 yr
 Multiparous
 Twinning
 Racial origin (black)
 Hypertension and eclamptic patients
 Nutritional deficiencies
 No family history
Diagnosis
Criteria
1.Development of Cardiac failure in the last month of pregnancy or
within 5 month after delivery
2. Absence of an identifiable cause for the cardiac failure.
3.Absence of recognizable heart disease prior to the last month of
pregnancy.
4.Left ventricular systolic dysfunction demonstrated by classic
Echo Cardio Graphic criteria such as depressed shortening
fraction or ejection fraction.
The National Heart, Lung and Blood Institute and the Office of rare diseases (1997)
Diagnosis
Criteria
1.Development of Cardiac failure in the last month of
pregnancy or within 5 month after delivery
2. Absence of an identifiable cause for the cardiac failure.
3.Absence of recognizable heart disease prior to the last
month of pregnancy.
4.Left ventricular systolic dysfunction demonstrated by
classic Echo Cardio Graphic criteria such as depressed
shortening fraction or ejection fraction.
The National Heart, Lung and Blood Institute and the Office of rare diseases (1997)
Diagnosis
Clinical Presentation
 Symptoms:
 Signs:
 Paroxysmal Nocturnal
 Cardiomegaly
Dyspnea
 Dyspnea on Exertion
 Cough
 Orthopnea
 Chest Pain
 Abdominal Discomfort
 Palpitation
 Gallop Rhythm
 Edema
 Holosystolic murmur
• Thromboembolic Manifestation
Diagnosis
Clinical Presentation
 Often unrecognized, as symptoms of normal
pregnancy commonly mimic those of mild heart
failure.
 In the absence of any cardiac symptoms, one of
the early indications about this condition is Fetal
growth retardation during evaluation of the fetus
with a fetal monitor and ultrasound
Diagnosis
Investigation
1.Chest X rays
 Cardiomegaly
with
pulmonary
oedema
 Pulmonary venous congestion.
2. The E.C.G
 Nonspecific ST and T wave changes
 Atrial or ventricular arrhythmias
and
 conduction defects
Diagnosis
Investigation
3.ECHO
 Enlargement of all four chambers




with marked reduction in left
ventricular systolic function
Small to moderate pericardial effusion
Mitral, tricuspid and pulmonary
regurgitation
Ventricular wall motion, ejection
fraction and cardiac output are
decreased .
Pulmonary wedge pressure is
increased.
Management
Consultations
Cardiologist
High-risk obstetrician
Anesthesiologist
- Neuraxial anesthesia is
preferred to avoid myocardial depression from
inhaled anesthetics; for this reason, as the mother
nears delivery, low-molecular-weight heparin
should be used with caution.
Management
Vigorous treatment of AHF
 Non-pharmacological
 Salt restriction (4gm/d)
 Water restriction (2 L/D)
 Pharmacological
 Pre-load reduction (diuretics, nitrates)
 After-load reduction (hydralazine, nitrates, amlodipine)
 ACE-I contraindicated during pregnancy
 Ionotropes (digoxin, dopamine, dobutamine)
 Beta-blockers
 Anticoagulant
Update in Management
Immunosuppressive agents
 May be initiated in patients with PPCM and
biopsy-proven myocarditis, but efficacy is unclear
 Empiric immunosuppression, in the absence of
evidence of myocarditis, is not currently
recommended
 Cardiac MRI could guide the immunosuppressive
therapy
Update in Management
pentoxifylline
Update in Management
Levosimendan
Update in Management
Bromocriptine
Update in Management
Since the disease may be reversible, the
temporary use of Intra Aortic Balloon
Pump or LV assist device may help to
stabilize the patient’s condition pending
improvement.
Update in Management
Cardiac Resynchronization Therapy and
Implantable Cardioverter/Defibrillators
 LV ejection fraction < 35% persists after 6
months following presentation.
 Patients with recurrent symptomatic ventricular
arrhythmias
 If NYHA III and IV heart failure symptoms and a
QRS duration > 120 ms
Update in Management
Cardiac Transplantation
Prognosis
 Prognosis seems dependent on recovery of left
ventricular function.
 30% of patients return to baseline ventricular function
within 6 months.
 The usual causes of death in patients with (PPCM) are
progressive heart failure, arrhythmia, or
thromboembolism (30%).
Prognosis
 There is an initial high risk period with mortality of 25-
50% in the first 3 months postpartum.
 Patients with persistent cardiomegaly at 6 months have
a reported mortality of 85% at 5 years.
 Subsequent pregnancies in women with PPCM are
often associated with relapses and high risk for
maternal morbidity and mortality.
 Should be discouraged in women with PPCM who have
persistent cardiac dysfunction.
Prognosis
 Several factors for deterioration:
 Age >30
 High Parity
 Later onset of six month Following pregnancy
 Worse Echo findings on initial exam
Elkayam et al. N Engl J Med 2001; 344:1567
REMEMBER
 PPCM mimics changes occurring in normal pregnancy
 Fetal growth retardation may point towards this
condition
 Treat like any other cardiac failure along with anti
coagulant therapy
 Epidural anaesthesia is preferable and continue
monitoring in an ICU
 Advice against subsequent pregnancies.
Any questions