Clinician-to-Clinician Update Clinician-to-Clinician Update

LVAD Placed as Long-Term Therapy for Postpartum Cardiomyopathy

May 2015

Postpartum cardiomyopathy occurs at an incidence rate of approximately 5 cases per 10,000 live births in the United States. 1 Mechanical ventricular assist devices can be used as a bridge to recovery or as a bridge to cardiac transplantation in this population.2 Here we describe a patient with severe heart failure secondary to postpartum cardiomyopathy who underwent left ventricular assist device (LVAD) placement and subsequent exchange with excellent long-term results at 8-years follow-up.

Patient

A 34-year-old female presented in 2007 to University of Minnesota Medical Center with severe cardiogenic shock secondary to postpartum cardiomyopathy. She had no significant medical history. She was initially stabilized with intravenous inotropes and an intra-aortic balloon pump. An echocardiogram revealed severe left ventricular dysfunction with an ejection fraction of 10%.

LHxray-443x353
— Figure 1. X-ray image of a 34-year-old female patient showing the successful placement of a HeartMate II® left ventricular assist device

Treatment

The patient underwent placement of a HeartMate II® LVAD (Thoratec Corp., Pleasanton, CA), which was intended initially as a bridge to heart transplantation (Figure 1). She recovered uneventfully after surgery. After a period of rehabilitation, she returned to work as an occupational therapist. Because the patient was highly sensitized (i.e., had previously developed antibodies against human leukocyte antigens), finding a compatible donor heart was very difficult, and it was decided to continue with LVAD in the long term. In 2014, after 7 years on LVAD support without a single readmission to the hospital, she presented with a driveline fracture that could not be repaired. The patient underwent surgical exchange of the LVAD pump via a left subcostal incision without sequelae. She is currently doing well and has returned to work.

Discussion

Although the implanted LVAD described in this case was intended to be a bridge to heart transplantation, the patient was highly sensitized, complicating the clinical situation. Highly sensitized patients are at very high risk for hyperacute rejection, posttransplantation rejection, and cardiac allograft vasculopathy.3 Therefore, LVAD was used as a destination therapy for this patient, with excellent long-term outcomes. This treatment approach is supported by research comparing long-term LVAD outcomes in patients with and without postpartum cardiomyopathy. In one study of 99 women with and 1,258 women without postpartum cardiomyopathy who were registered in Interagency Registry for Mechanically Assisted Circulatory Support between June 2006 and March 2012, the rate of survival in the postpartum cardiomyopathy group was 68% at 3 years compared with 52% in the group without postpartum cardiomyopathy. The authors conclude that the improved survival observed in the postpartum cardiomyopathy group was likely related to fewer comorbidities and younger age, as seen in the case patient.

References

1. Gunderson EP, Croen LA, Chiang V, et al. Epidemiology of peripartum cardiomyopathy: incidence, predictors, and outcomes. Obstet Gynecol. 2011;118:583-591.

2. Zimmerman H, Bose R, Smith R, et al. Treatment of peripartum cardiomyopathy with mechanical assist devices and cardiac transplantation. Ann Thorac Surg. 2010;89:1211-1217.

3. Eckels DD, Stehlik J, Kfoury AG. The detection and role of circulating antibodies in rejection. Curr Opin Organ Transplant. 2013;18:589–594.

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