Elsevier

American Heart Journal

Volume 140, Issue 5, November 2000, Pages 785-791
American Heart Journal

Congestive Heart Failure
Myocarditis and long-term survival in peripartum cardiomyopathy

https://doi.org/10.1067/mhj.2000.110091Get rights and content

Abstract

Background The reported mortality rate of peripartum cardiomyopathy (PPCM) is high, although the potential for spontaneous recovery of ventricular function is well established. The prevalence of myocarditis in PPCM has varied widely between studies. The purposes of this study were to define the long-term prognosis in a referral population of patients with PPCM, to determine the prevalence of myocarditis on endomyocardial biopsy in this population, and to identify clinical variables associated with poor outcome. Methods We analyzed clinical, echocardiographic, hemodynamic, and histologic features of 42 women with PPCM evaluated at our institution over a 15-year period. Each patient underwent an extensive evaluation, including echocardiography, endomyocardial biopsy, and right heart catheterization. Data were analyzed to identify features at initial examination associated with the combined end point of death or cardiac transplantation by the use of Kaplan-Meier survival curves and a Cox proportional hazards model. Results Three (7%) patients died and 3 (7%) patients underwent heart transplantation during a median follow-up of 8.6 years. Endomyocardial biopsy demonstrated a high prevalence of myocarditis (62%), but the presence or absence of myocarditis was not associated with survival. Of the prespecified variables assessed, only decreased left ventricular stroke work index was associated with worsened outcome. Conclusions In patients with PPCM, (1) long-term survival is better than has been historically reported, (2) the prevalence of myocarditis is high, and (3) decreased left ventricular stroke work index is associated with worse clinical outcomes. (Am Heart J 2000;140:785-91.)

Section snippets

Patients

All patients undergoing endomyocardial biopsy at The Johns Hopkins Hospital between 1983 and 1998 with a diagnosis of possible PPCM were retrospectively reviewed. Patients were included if they met the following criteria: (1) onset of left ventricular dysfunction in the last month of pregnancy or the first 5 months after delivery, (2) no evidence of preexisting left ventricular dysfunction, (3) no other explanation for left ventricular dysfunction, and (4) initial evaluation within 2 years of

Patient characteristics

Clinical and obstetric characteristics are shown in Table I.

. Clinical characteristics of 42 patients with PPCM

Age (y)29 ± 6
Race
 White52%
 Black46%
 Hispanic2%
Parity
 147%
 224%
 313%
 >316%
Multiple gestations
 Single88%
 Twin12%
Type of delivery
 Vaginal62%
 Cesarean38%
Hypertension*
 Chronic17%
 Gestational26%
 Eclampsia/preeclampsia0%
 None57%
Diabetes mellitus
 Gestational2%
 None98%
Alcohol use
 During pregnancy7%
 Before pregnancy2%
 None91%
Tobacco use
 During pregnancy40%
 None60%
*Chronic, Blood pressure >140/90 before 20 weeks of

Discussion

The current study is the largest reported series of patients with PPCM that used strict diagnostic criteria. This series attempts to determine the long-term survival, assess the prevalence of myocarditis, and identify factors associated with prognosis in a relatively large series of patients who have undergone a standardized clinical evaluation at a single institution. The natural history of PPCM is variable, with some patients demonstrating recovery of left ventricular function and others

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Reprint requests: Kenneth L. Baughman, MD, Division of Cardiology, Blalock 568, Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287. E-mail: [email protected]

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