Peripartum cardiomyopathy (PPCM) is presenting at the end of pregnancy or within 6 months postpartum with left ventricular dysfunction with EF <45%. Incidence is estimated to be 1:1000-4000. Rates of recovery ranging from 29 – 72% and mortality 25%.Management including medical therapy, cardiac devices, and heart transplant. Available published data showing three reported cases of PPCM with LBBB for whom Cardiac resynchronisation therapy [CRT] was implanted
A 36-year-old woman, presented 3 months postpartum with severe dyspnea (NYHA III), she has non relevant past medical history. Echocardiography showed LVEF 25% and severe MR, diagnosed as PPCM
Medical therapy was started with carvedilol, ramipril, indapamide, and spironolactone. After 17 months, despite the maximum tolerated dose of medical therapy, LV function did not improve and her symptoms worsen. Her ECG showed LBBB. Post CRT implantation, her LVEF recovers after 3 months, reaching 60% at 7 month follow up with dramatic improvement in her symptoms (NYHA I).
Conclusion and implication for clinical practice
CRT could be considered for optimizing LV function recovery in patients with PPCM despite optimal medical therapy. Comparing with the other two published cases, first case was refractory for medical therapy for 9 years with EF 28%, reached 55% six-month after CRT. Second case, her EF was 25% over 6 years, then 45% six-month post CRT. According to the current guideline in heart failure, eligibility for CRT should be evaluated after 6 months, however, the possibility of PPCM recovery make the early decision of CRT challenging. Moreover, the current data regarding use of CRT in PPCM is limited and there is a lack of precise follow up. Therefore, we need focus and orientation regarding this topic to bridge the gap of evidence to determine predictor factors for optimum time of CRT implantation in patients who are refractory to medical management