Peripartum Cardiomyopathy Presenting with Predominant Left Ventricular Diastolic Dysfunction: Efficacy of Bromocriptine
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Abstract:
Management of patients with peripartum cardiomyopathy (PPCM) is still a major clinical problem, as only half of them or slightly more show complete recovery of left ventricular (LV) function despite conventional evidence-based treatment for heart failure. Recent observations suggested that bromocriptine might favor recovery of LV systolic function in patients with PPCM. However, no evidence exists regarding its effect on LV diastolic dysfunction, which is commonly observed in these patients. Tissue Doppler (TD) is an echocardiographic technique that provides unique information on LV diastolic performance. We report the case of a 37-year-old white woman with heart failure (NYHA class II), moderate LV systolic dysfunction (ejection fraction 35%), and severe LV diastolic dysfunction secondary to PPCM, who showed no improvement after 2 weeks of treatment with ramipril, bisoprolol, and furosemide. At 6-week followup after addition of bromocriptine, despite persistence of LV systolic dysfunction, normalization of LV diastolic function was shown by TD, together with improvement in functional status (NYHA I). At 18-month followup, the improvement in LV diastolic function was maintained, and normalization of systolic function was observed. This paper might support the clinical utility of bromocriptine in patients with PPCM by suggesting a potential benefit on LV diastolic dysfunction.Keywords:
Peripartum Cardiomyopathy
The objective: to evaluate changes in transmitral blood flow indices asmarkers of myocardial diastolic function using Doppler echocardiography with an increase in the severity of chronic heart failure (CHF).Materials and methods. 84 patients with CHF II-III FC were examined. Evaluation of left ventricular (LV) diastolic function was carried out by the Doppler-echocardiography method in pulsed mode on a Toshiba SSH-160A apparatus (Japan) using a 3.5 MHz transducer based on transmitral diastolic blood flow.Results. The analysis showed that if in patients with CHF II FC,LV myocardial hypertrophy dominates in the pathogenesis, then in patients with CHF III FC there is systolic dysfunction. The main pathogenetic factor in the increase in the severity of CHF from II to III FC is diastolic dysfunction.Conclusion. In patients with CHF II FC in an intact left atrium, impaired transmitral diastolic blood flow occurs in the «slow relaxation» mode. Patients with CHF II FC against the background of an increased size of the left atrium, especially in the presence of post-infarction cardiosclerosis and arrhythmias, are diagnosed with a «pseudonormal» type of transmitral blood flow. The majority of patients with CHF III FC are diagnosed with a «restrictive» type of transmitral blood flow.
Diastolic heart failure
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Nearly half of patients with symptoms of heart failure are found to have an left ventricular (LV) ejection fraction which is within normal limits. These patients have variously been labeled as having diastolic heart failure, heart failure with preserved LV function or heart failure with normal ejection fraction (HFNEF). Since recent studies have shown that systolic function is not entirely normal in these patients, HFNEF is the better term. More common in elderly females it has a mortality similar to heart failure with a reduced ejection fraction (HFREF). The exact pathophysiology of the symtpoms is still not clear and, therefore, debated. As heart failure is often episodic, the underlying abnormal mechanisms may not be completely apparent at rest. It is likely there is a mixture of systolic and diastolic dysfunction which will be different to some degree in individual patients and isolated diastolic dysfunction or primary abnormalities of relaxation are probably extremely rare. The main difference between HFNEF and HFREF is the degree of ventricular remodeling with increased ventricular volumes in HFREF. The time course of remodeling depends to some extent on the aetiology being quicker post myocardial infarction--the commonest cause of HFREF, and slower with hypertension which is the most frequent aetiological factor in HFNEF. Ventricular volumes rather than ejection fraction or the concept of a pure diastolic abnormality can be used to classify patients in a more rational manner.
Diastolic heart failure
Ventricular remodeling
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To assess whether contractile reserve during dobutamine stress echocardiography (DSE) can predict left ventricular functional recovery in patients with peripartum cardiomyopathy and to assess myocardial fibrosis by magnetic resonance imaging (MRI) in these patients. Nine patients with peripartum cardiomyopathy were enrolled. All patients underwent DSE and were followed for six months, when a rest Doppler echocardiogram was repeated. MRI was also performed at the beginning of follow-up to identify myocardial fibrosis. Mean age was 29 ± 7.9 years and mean left ventricular ejection fraction at baseline was 39.4 ± 8.6% (range 24–49%). Eight of the nine patients showed left ventricular functional recovery with mean ejection fraction at follow-up of 57.1 ± 13.8%. The ejection fraction response to DSE did not predict recovery at follow-up. On the other hand, left ventricular ejection fraction at baseline correlated with ejection fraction at follow-up. Mild fibrosis was detected in only one patient. Left ventricular ejection fraction at baseline was a predictor of left ventricular functional recovery in patients with peripartum cardiomyopathy. Dobutamine stress echocardiography at presentation of the disease did not predict recovery at follow-up. Myocardial fibrosis appeared to be uncommon in this cardiomyopathy. Avaliar se a reserva contrátil durante o ecocardiograma de estresse com dobutamina (EED) pode predizer a recuperação funcional do ventrículo esquerdo em pacientes com miocardiopatia periparto e também acessar a fibrose miocárdica através da ressonância nuclear magnética (RNM) nestas pacientes. Nove pacientes com miocardiopatia periparto foram incluídas. Todas as pacientes foram submetidas ao EED e acompanhadas por 6 meses, quando um novo ecocardiograma de repouso foi realizado. A RNM também foi realizada no início do seguimento para identificar fibrose miocárdica. A idade média das pacientes foi de 29 ± 7,9 anos e a fração de ejeção basal média do ventrículo esquerdo foi de 39,4 ± 8,6% (variando de 24 a 49%). Oito das nove pacientes tiveram recuperação funcional do ventrículo esquerdo, com fração de ejeção média no seguimento de 57,1 ± 13,8%. A resposta da fração de ejeção ao EED não foi um preditor de recuperação no seguimento. Por outro lado, a fração de ejeção basal teve correlação com a fração de ejeção no seguimento. Fibrose discreta foi detectada em apenas uma paciente. A fração de ejeção basal do ventrículo esquerdo foi um preditor de recuperação funcional ventricular em pacientes com miocardiopatia periparto. O EED na apresentação da doença não foi um preditor de recuperação no seguimento. Fibrose miocárdica pareceu ser incomum nesta miocardiopatia.
Peripartum Cardiomyopathy
Dobutamine
Myocardial fibrosis
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Diastolic heart failure
Isovolumic relaxation time
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Objective To determine whether patients with suspected heart failure but preserved left ventricular ejection fraction (LVEF) had systolic and diastolic dysfunction in left ventricular long axis detected by tissue Doppler echocardiographic indexes. Methods The data of 100 patients with heart failure who admitted to our hospital between August 2007 and October 2009 were collected. Heart failure with preserved LVEF was diagnosed in 50 patients and heart failure with reduced LVEF was diagnosed in another 50 patients. Fifty age-matched healthy subjects served as the control group.Tissue Doppler imaging indexes (Sm, Ea, Aa, E/Ea) and plasma BNP concentration were compared among the three groups. Results The degree of Sm decrease was more significant in heart failure patients with reduced LVEF than those with preserved LVEF. In the two subjects, the index Sm was negatively correlated with the BNP concentration (r=-0.35, P<0.05).The indexes E/Ea was positively correlated with the BNP concentration (r=0.728, P<0.05). Conclusions The LV filling index E/Ea is identified as the best index to detect diastolic dysfunction in heart failure but preserved left ventricular ejection fraction.
Key words:
Heart failure; Ventricular function; Echocardiography
Doppler imaging
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Isovolumic relaxation time
Diastolic heart failure
Isovolumetric contraction
Systole
Doppler imaging
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Doppler imaging
Diastolic heart failure
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Ischemic Cardiomyopathy
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Diastolic heart failure
Hypertensive heart disease
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A reduced left ventricular ejection fraction measured by echocardiography in a patient with clinical features of heart failure demonstrates that the patient has a cardiac abnormality and that the clinical picture is, in fact, due to heart failure. As such, a reduced ejection fraction (< 0.30 or 0.35) has been used as entry criteria for almost all the large clinical trials that guide our therapy of patients with heart failure. However, it has been recently recognized that a substantial and increasing proportion of patients with heart failure have a normal ejection fraction (> 0.50). Such patients are typically elderly women with systolic hypertension. These patients are subject to the sudden development of pulmonary congestion (flash pulmonary edema). The finding of heart failure in patients with a normal ejection fraction has focused attention on the role of diastolic dysfunction in producing symptomatic heart failure. The optimal treatment of patients with heart failure and normal ejection fraction has not yet been defined, but the control of systolic hypertension and the avoidance of fluid overload are important.
Diastolic heart failure
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