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Peripartum myocarditis and cardiomyopathy
M G Midei1, S H DeMent, A M Feldman
1Johns Hopkins Medical Institutions, Department of Medicine, Baltimore, Maryland.
Insights
Peripartum cardiomyopathy often involves myocarditis. Immunosuppressive therapy may improve outcomes for patients with persistent left ventricular dysfunction, though some cases resolve spontaneously.
Area of Science:
- Cardiology
- Pathology
Background:
- Peripartum cardiomyopathy (PPCM) is a rare form of heart failure.
- The role of myocarditis in PPCM and the efficacy of immunosuppressive therapy remain areas of investigation.
Purpose of the Study:
- To determine the incidence of myocarditis in PPCM.
- To evaluate the response of PPCM patients with myocarditis to immunosuppressive agents.
Main Methods:
- Retrospective analysis of 18 PPCM patients.
- Evaluation included echocardiography, nuclear ventriculography, right heart catheterization, and myocardial biopsy.
- Myocardial biopsy was used to diagnose myocarditis and assess treatment response.
Main Results:
- Myocarditis was present in 78% of PPCM patients.
- Nine of ten patients treated with immunosuppressives showed improvement.
- Follow-up biopsies indicated resolution or improvement of myocarditis.
- Four patients without myocarditis had varied outcomes, including two requiring transplantation.
Conclusions:
- Myocarditis is a frequent finding in PPCM.
- Resolution of myocarditis correlates with improved left ventricular function.
- Immunosuppressive therapy may benefit PPCM patients with persistent left ventricular dysfunction.
Abstract:
The clinical and pathologic features of 18 consecutive patients with peripartum cardiomyopathy at The Johns Hopkins Hospital were examined in an attempt to define the incidence of myocarditis and to determine its response to immunosuppressive agents. In addition to routine studies, patients were evaluated with echocardiography, nuclear ventriculography, right heart catheterization, and myocardial biopsy. Fourteen of the 18 patients (78%) showed evidence of myocarditis. Of these, 10 were treated with immunosuppressive therapy. Nine of the 10 treated patients with myocarditis had subjective and objective improvement. Follow-up endomyocardial biopsies in these patients showed resolution or substantial improvement in myocarditis. Four patients with myocarditis not treated with immunosuppressives also improved. All patients improving spontaneously presented with congestive heart failure within 1 month of delivery and improved dramatically within days of presentation. Four of the 18 patients showed no evidence of myocarditis. Of these, two improved, and two deteriorated (both requiring cardiac transplantation). None of these four patients were treated with immunosuppressive therapy. We conclude that in patients with peripartum cardiomyopathy, 1) the etiology remains unclear although myocarditis was present in 78% of those with this condition, 2) resolution of myocarditis is associated with significant improvement in left ventricular function, 3) myocarditis may resolve spontaneously without detectable loss of cardiac function, and 4) immunosuppressive therapy in patients with myocarditis and persistent left ventricular dysfunction may improve left ventricular function and prognosis.