Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

American Journal of Emergency Medicine 33 (2015) 1713.e1-1713.e2

Predelivery extracorporeal membrane oxygenation in a life-threatening peripartum cardiomyopathy: save both mother and child?

Abstract

Peripartum cardiomyopathy (PPCM) refers to the development of heart failure in the last month before or within 5 months after delivery in the absence of preexisting heart disease. In critically ill PPCM patients unresponsive to medical therapy, extracorporeal membrane oxygenation may be considered even before delivery as a bridge to recovery or as a bridge to heavier mechanical support. We describe the case of a 29 year-old White patient admitted for severe HF developed during the last month of pregnancy. Profound left ventricular systolic dysfunction was consistent with PPCM. Predelivery peripheral venoarterial ECMO was implanted as Circulatory mechanical support allowing for a successful fetal extraction by Cesarean-section (C-section). The patient underwent left ventricular assistance device implantation at day 21, as she did not recover. Mother and child are doing well at 3-month follow-up. Predelivery ECMO is therefore a valuable option in severe cases of HF complicating PPCM during late pregnancy.

A previously healthy 29-year-old White female patient presented with a 2 weeks’ history of severe congestive heart failure occurring during the last month of her second pregnancy. At admission, blood pressure was at 80/65 mm Hg, heart rate at 120 beats per minute, and oxygen saturation at 85%. Signs of low-cardiac output were found. Chest x-ray displayed cardiomegaly, Pleural effusions, and vascular redistribu- tion indicating central fluid accumulation (Figure). Bedside transthoracic echocardiography revealed left ventricular (LV) severe dysfunction. Ino- tropic therapy with dobutamine along with intravenous diuretics did not produce any hemodynamic improvement. Meanwhile, obstetrical monitoring revealed fetal distress signs. The patient underwent urgent femoral venoarterial Extracorporeal membrane oxygenation im- plantation along with intra-aortic balloon counterpulsation implantation enabling hemodynamic stabilization and rescue fetal extraction by C-section. The infant was discharged from Neonatal intensive care unit at day 7. As LV dysfunction did not recover despite ECMO and inotropic sup- port, LV assist device (HVAD; HeartWare Inc, Miami Lakes, FL) was then implanted electively at 3 weeks. The postoperative course was uneventful. Mother and child are both doing well at 3-month follow-up. Close trans- thoracic echocardiography monitoring displays progressive decrease in LV end-diastolic diameter and improvement in LV ejection fraction.

Peripartum cardiomyopathy (PPCM) refers to the development of HF

due to systolic dysfunction in the last month before or within 5 months after delivery in the absence of preexisting heart disease. Diagnostic criteria have been recently revised by the European Society of Cardiology (ESC) Working Group on PPCM [1]. It is a life-threatening condition that

? Conflict of interest: none.

carries a high morbidity and mortality rate as well as the possibility of re- covery ad integrum. Refractory cardiogenic shock revealed PPCM in our previously healthy 29-year-old patient. Peripartum cardiomyopathy diagnosis was consistent with the ESC Working Group on PPCM criteria [1]. Short-term Mechanical circulatory support was implanted, as the patient’s condition did not improve in spite of intensive medical thera- py. Predelivery ECMO along with intra-aortic balloon counterpulsation allowed for a rapid hemodynamic stabilization and fetal extraction and thereby avoiding maternal and fetal brain damage. Published data related to the safety of peripheral ECMO in critically ill PPCM patients are scarce [2-4]. Moreover, the clinical course of PPCM is highly variable. Up to one-third of patients will improve their LV function within the first 6 months postpartum [5]. Left ventricular assist devices offer safe and effective therapy for severe HF patients who deteriorate despite inotropic drug therapy or in those who cannot be weaned from short- term assistance devices. There are few data related to myocardial recovery in PPCM patients treated by left ventricular assist devices [6,7]. Long-term mechanical assist support is nevertheless preferred in this specific population due to the significant rate of delayed recovery [1].

In unresponsive cardiogenic shock complicating PPCM, predelivery short-term mechanical circulatory support allows lifesaving management of both mother and child and allows for rescue fetal extraction. As LV

Figure. Chest x-ray at admission showing features of pulmonary edema (alveolar opacities and bilateral pleural effusion) along with cardiomegaly.

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recovery may be delayed in PPCM patients, long-term assist devices are valuable options when short-term assistance devices cannot be weaned.

Nadia Bouabdallaoui, MD? Ciro Mastroianni, MD Luca Revelli, MD Pierre Demondion, MD

Guillaume Lebreton, MD Department of Thoracic Cardiovascular Surgery Pierre Marie Curie University Paris VI, Paris, France Assistance publique des hopitaux de Paris La Pitie Salpetriere Hospital Paris, France

?Corresponding author. Department of Thoracic and Cardiovascular

Surgery, La Pitie-Salpetriere Hospital, 47-83 Boulevard de l’Hopital Paris, France. Tel.: +33 1 84 82 71 77; fax: +33 1 42 16 56 39

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.03.014

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