Mechanical Circulatory Support Strategies for Cardiogenic Shock Secondary to Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a severe complication of pregnancy hallmarked by nonischemic reduction in left ventricular ejection fraction to <45% late in gestation or shortly postpartum. This study evaluated outcomes among women who required mechanical circulatory support (MCS) for end-stage heart failure in the setting of PPCM.

Thirty female patients 18-46 years of age underwent advanced heart failure surgical procedures for PPCM between 2012 and 2020. Primary heart transplant patients (n = 2) were excluded. PPCM patients with a new MCS requirement (n = 28) were classified by device type and escalations in device support.

Nineteen (68%) patients required temporary MCS: 12 (63%) intraaortic balloon pump, 9 (47%) venous-arterial extracorporeal membrane oxygenation, and 4 (21%) Impella heart pump (AbioMed Inc). Nine (32%) patients underwent left ventricular assist device implantation immediately after failure of medical therapy. Among temporary MCS recipients, 5 (26%) required escalations with additional modalities. Ten (53%) patients were bridged to durable left ventricular assist devices. Ejection fraction at MCS insertion was 14% ± 5% and progressed to 24% ± 16% postinsertion and 29% ± 17% 1 year after surgery. Complications included dialysis requirement (n = 5), right ventricular failure (n = 4), cardiac arrest (n = 3), and stroke (n = 2). Survival to discharge was 89% (n = 25). Twelve patients underwent transplant (43%), and 2 (7%) recovered native heart function.

Severe PPCM can be effectively managed with MCS as a bridging strategy to either transplant or durable left ventricular assist device. Patients will often require multiple escalations in resource-intensive therapy, but outcomes are excellent with vigilant management.