Association between RV Function in PPCM and LV Recovery & Clinical Outcome Lori A Blauwet, MD, MA Associate Professor of Medicine Co-Director, Cardio-OB Clinic Mayo Clinic Rochester, MN USA 2016 MFMER slide-1
Objectives 1. Describe the impact of right ventricular (RV) size & function on outcomes in patients with PPCM 2. Compare racial differences in RV findings among patients with PPCM 3. Illustrate importance of long-term follow-up in patients with PPCM 2016 MFMER slide-2
Case: Day 1 25 yo collapses outside her home Husband performs CPR Paramedics defibrillate Admitted to local hospital Alert and oriented 2016 MFMER slide-3
V fib arrest Case: Day 2 Hypoxic, unresponsive Cath Lab Normal coronary arteries IABP placed PEA arrest; resuscitated Intermittent ventricular tachycardia Transferred to Mayo Clinic 2016 MFMER slide-4
Case: Day 3 Cardiogenic shock Frequent VT requiring multiple shocks Respiratory failure Unresponsive despite no sedation 2016 MFMER slide-5
Case Past Medical History Previously healthy Nonsmoker, no drugs No family history FT student Running 2 miles daily G2P2 (2 nd baby born 12 weeks prior) 2016 MFMER slide-6
Case: ECG 2016 MFMER slide-7
Left ventricle Right ventricle 2016 MFMER slide-8
Left ventricle Right ventricle 2016 MFMER slide-9
What is the prognosis? 2016 MFMER slide-10
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McNamara D. JACC, 2015 2016 MFMER slide-12
Univariate Predictors of low LVEF at 12M Black race Dx >6 weeks after delivery baseline LVEF Large LVEDD BMI McNamara D. JACC, 2015 2016 MFMER slide-13
Fixed Effect Beta SE P value Multivariate Baseline LVEF 0.04 0.14 0.79 Baseline LVEDD -0.66 0.17 <0.0001 Black -26.03 7.99 0.002 BMI -0.04 0.15 0.77 Time postpartum -0.06 0.04 0.18 2016 MFMER slide-14
What does the literature tell us about cardiac structure & function in PPCM patients? LV RV 2016 MFMER slide-15
Right Ventricular Function in Peripartum Cardiomyopathy at Presentation Is Associated with Subsequent Left Ventricular Recovery and Clinical Outcomes Results of the IPAC Study Investigations of Pregnancy-Associated Cardiomyopathy Blauwet LA. Circ Heart Fail; in press 2016 MFMER slide-17
Right Ventricular Parameters Right atrial size Right ventricular size Linear dimensions End-diastolic and end-systolic area Right ventricular systolic function TAPSE TDI basal lateral wall Strain Estimated pulmonary artery pressures 2016 MFMER slide-19
Pre-Specified Endpoints LV recovery LVEF 50% at 1 year Persistent severe LV dysfunction LVEF 35% at 1 year Major events Death, transplant, or LV assist device (LVAD) implantation 2016 MFMER slide-20
Right ventricular area Normal RV EDA: 25 cm 2 Normal RV ESA: 14 cm 2 2016 MFMER slide-21
RV End Diastolic Area (EDA) RV End Systolic Area (ESA) = FAC FAC: Fractional Area Change, % RV End Diastolic Area (EDA) Normal FAC >35% 2016 MFMER slide-22
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LVEF <50% or Event Predictor Hazard ratio Univariable 95% C.I. P value Age 0.97 0.90-1.04 0.41 Black race 2.10 0.87-5.02 0.09 LV EF, % 0.91 0.86-0.95 <0.001 LV EDD, mm 1.10 1.03-1.17 0.03 RV FAC, % 0.94 0.91-0.97 <0.001 RV EDA, mm 1.09 1.02-1.17 0.02 RV ESA, mm 1.13 1.06-1.22 <0.001 RV free wall strain, % 1.13 1.04-1.24 0.006 TAPSE 0.97 0.89-1.06 0.52 2016 MFMER slide-24
LVEF <35% or Event Predictor Hazard ratio Univariable 95% C.I. P value Age 0.93 0.85-1.03 0.19 Black race 2.97 0.90-9.80 0.08 LV EF, % 0.86 0.80-0.92 <0.001 LV EDD, mm 1.10 1.03-1.21 0.01 RV FAC, % 0.92 0.84-0.96 <0.001 RV EDA, mm 1.10 1.02-1.17 0.02 RV ESA, mm 1.17 1.06-1.29 0.002 RV free wall strain, % 1.15 1.00-1.21 0.05 TAPSE 0.89 0.78-1.01 0.08 2016 MFMER slide-25
Predictor Hazard ratio* 95% C.I. P value Multivariable RV FAC, % 0.95 0.92-0.99 0.02 RV ESA, mm 1.08 1.00-1.17 0.06 RV free wall strain, % 1.07 0.96-1.19 0.24 *Adjusted for black race, baseline LVEF & baseline LV EDD 2016 MFMER slide-26
RV ESA: 2016 MFMER slide-27
Parameter Black N=26 Non-black N=65 P value LV EF, % 32 (9.1) 36 (8.7) 0.05 LV EDD, mm 58 (6.8) 55 (6.2) 0.03 LV ESD, mm 49 (7.2) 45 (7.4) 0.03 RV EDA, cm 2 21 (6.4) 20 (5.5) 0.40 RV ESA, cm 2 14 (5.1) 12 (5.0) 0.30 RV FAC, % 36 (10.3) 39 (12.1) 0.26 TAPSE, mm 20 (5.4) 20 (4.6) 0.94 RV free wall strain, % -17 (5.4) -17 (6.7) 0.97 2016 MFMER slide-28
Parameter Race Baseline LV EF, % LV EDD, mm LV ESD, mm RV EDA, cm 2 RV ESA, cm 2 RV FAC, % RV free wall strain, % Black Non-black Black Non-black Black Non-black Black Non-black Black Non-black Black Non-black Black Non-black 32 (9.3) 37 (7.6) 59 (6.7) 55 (6.2) 50 (7.5) 45 (7.3) 20 (6.5) 20 (5.6) 13 (5.1) 12 (4.9) 37 (10.5) 39 (11.4) -18 (5.4) -18 (6.8) Last Echo 48 (13.9) 55 (7.0) 54 (9.1) 49 (5.6) 41 (12.2) 34 (5.9) 20 (6.4) 18 (4.8) 12 (6.2) 10 (3.5) 43 (12.8) 45 (8.8) -19 (6.4) -22 (4.9) P value <0.001 <0.001 0.001 <0.001 0.001 <0.001 0.99 0.07 0.50 0.002 0.07 0.002 0.38 0.002 2016 MFMER slide-29
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Back to the Case December 2007: LVEF ~10%, mod-sev RV function LVAD implantation 3 months later: LVEF 45%, mod RV function 6 months later: LVEF 50%, mod RV function; LVAD drivelines removed 4 yrs later (2011): LVEF 55%, mild-mod RV function 5 yrs later (2012): A fib, VT, ICD shocks 6 yrs later (2013): LVEF 30%; mod RV function CRT-D implanted; LVEF 36%; mod RV function 7 yrs later (2014): SCD at home; no autopsy 2016 MFMER slide-34
Take Home Points In patients with newly diagnosed PPCM, 1. RV size predicts outcome 2. RV FAC predicts outcome 3. LV EDD predicts outcome 4. LV EF does NOT predict outcome 2016 MFMER slide-35
Final Take Home Point Patients with PPCM may develop heart failure relapse years after diagnosis even outside the context of subsequent pregnancy, so Patients with PPCM require long-term follow-up! 2016 MFMER slide-36
Thank you! blauwet.lori@mayo.edu 2016 MFMER slide-37
Questions & Discussion blauwet.lori@mayo.edu 2016 MFMER slide-38