Intra-aortic Balloon Pump as a Bridge to Recovery for Peripartum Cardiomyopathy in Cardiogenic Shock

Dear Editor,

Cardiac failure without identifiable cause, left ventricular (LV) systolic dysfunction with ejection failure <45%, or fractional shortening <30%, or both, on echocardiography, no recognizable heart disease prior to last month of pregnancy distinguish peripartum cardiomyopathy (PPCM), afflicting women in the last month of pregnancy or up to 5 months postdelivery.^{1, 2} PPCM is a diagnosis of exclusion. Variable clinical course makes management of this entity a challenge. Use of intra-aortic balloon pump (IABP), a mechanical circulatory device, may be considered for nonischemic cardiomyopathy-related systolic dysfunction.

A 27-year-old lady G1P1L1 premorbidly healthy was hospitalized at 36 weeks gestation with fever and generalized body ache. Examination revealed tachycardia at 132 beats/min, blood pressure of 80/50 mmHg, saturations at 85% on room air, and drowsiness. She was electively intubated and ventilated. Post-fluid resuscitation, norepinephrine, and vasopressin were added. Elective caesarean section was performed. Medical management included transfusion of blood products, antibiotics, and IABP to support her unstable hemodynamics. Bedside echocardiography revealed LVEF 30%, pulmonary artery systolic pressures (PASP) of 50 mmHg, moderate mitral regurgitation, and noncollapsing inferior vena cava. Trends of hemodynamic parameters are depicted in Graph 1. On intensive care unit (ICU) day 2, vasoactive requirements reduced. She was weaned off the ventilator and extubated the same evening. Saturations were maintained on Hudson mask with 6 L/min of oxygen. IABP was weaned off and removed on ICU day 4. Hemodynamics were maintained with a good peripheral perfusion. Beta-blockers were introduced. A repeat echo on ICU day 6 revealed LVEF 36%, PASP 35 mmHg, mild mitral regurgitation, and a collapsing inferior vena cava. Stabilized, she was discharged after 12 days of hospital stay.

Figure 1.

Hemodynamic parameter trends.

Large volume shifts following relief of inferior vena caval obstruction postdelivery, and autotransfusion lead to volume overloading. Volume overloading and tachycardia likely contributed to her acute decompensation. Improved balance between oxygen supply and demand after off-loading left ventricle improves cardiac performance and systemic perfusion. Her condition stabilized after insertion of IABP.

Temporary mechanical circulatory support (IABP, LV assist device, or extracorporeal membrane oxygenation) in patients with cardiogenic shock is used as a bridge to myocardial recovery or in those with refractory cardiac failure, as a bridge to transplantation. ³ Risk of recurrent heart failure in those who have not had complete recovery of LV function remains high. Spectrum of LV systolic function recovery ranges from rapid return to normal, persistence of dysfunction, slow return to normal over several years, to rapid deterioration requiring cardiac transplantation or even death.^{3, 4} Cardiovascular complications during pregnancy and in the puerperium influence maternal morbidity and mortality. Maternal age of <20 years, tachycardia, hypotension, LVEF <25%, ⁵ and anemia at baseline are independent predictors of mortality. Patient-specific clinical presentation, imaging parameters, biomarkers, and disease-specific information help in diagnosis.

Cardiogenic shock with hypoperfusion and end-organ involvement require emergency medical treatment and mechanical circulatory support. IABP can be a treatment of choice for off-loading left ventricle in this group of nonischemic cardiogenic shock that benefits in terms of bridge to recovery.