ABC | Volume 110, Nº2, February 2018

Original Article Heart Transplantation for Peripartum Cardiomyopathy: A Single‑Center Experience Nadia Bouabdallaoui, 1 Pierre Demondion, 1 Sylvestre Maréchaux, 2 Shaida Varnous, 1 Guillaume Lebreton, 1 Frédéric Mouquet, 3 Pascal Leprince 1 Department of Cardiac Surgery, La Pitié Salpêtrière, Assistance Publique des Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6; 1 GCS- Groupement des Hôpitaux de l’Institut Catholique de Lille, Cardiology Department and Heart Valve Center, Faculté Libre de Médecine/Université Catholique de Lille; 2 Service de Cardiologie, Pôle Cardio-vasculaire et Pulmonaire, Hôpital Cardiologique, 3 CHRU Lille, Lille Cedex, France Mailing Address: Nadia Bouabdallaoui • 47-83 Boulevard de l’Hôpital. 75013. Paris E-mail: nadia.bouabdallaoui@gmail.com Manuscript received March 12, 2017, revised manuscript August 02, 2017, accepted August 29, 2017 DOI: 10.5935/abc.20180014 Abstract Background: Peripartum cardiomyopathy is an idiopathic disorder defined by the occurrence of acute heart failure during late pregnancy or post-partum period in the absence of any other definable cause. Its clinical course is variable and severe cases might require heart transplantation. Objective: To investigate long-term outcomes after heart transplantation (HT) for peripartum cardiomyopathy (PPCM). Methods: Out of a single-center series of 1938 HT, 14 HT were performed for PPCM. We evaluated clinical characteristics, transplant-related complications, and long-term outcomes, in comparison with 28 sex-matched controls. Primary endpoint was death from any cause; secondary endpoints were transplant-related complications (rejection, infection, cardiac allograft vasculopathy). A value of p < 0.05 was considered of statistical significance. Results: PPCM patients and matched controls were comparable for most variables (all p values > 0.05), except for a higher use of inotropes at the time of HT in PPCM group (p = 0.03). During a median follow-up of 7.7 years, 16 patients died, 3 (21.5%) in PPCM group and 13 (46.5%) in control group. Mortality was significantly lower in PPCM group (p = 0.03). No significant difference was found in terms of transplant-related complications (p > 0.05). Conclusions: Long-term outcomes following HT for PPCM are favorable. Heart transplantation is a valuable option for PPCM patients who did not recover significantly under medical treatment. (Arq Bras Cardiol. 2018; 110(2):181-187) Keywords: Heart Failure; Cardiomyopathies / mortality; Peripartum Period; Heart Transplantation; Graft Rejection. / mortality. Introduction Peripartum cardiomyopathy (PPCM) is defined by the occurrence of acute heart failure (HF) during late pregnancy or post-partum period in the absence of any other definable cause or prior heart disease. Diagnostic criteria have recently been revised by the ESCWorking Group on PPCM. 1 Disease incidence shows ethnic variations, with a greater prevalence among African women. 2 A deleterious combination of “anti angiogenic signaling excess” and “oxidative stress‑prolactin axis” toward the end of pregnancy is suggested as key element in the pathophysiology of the disease. 3 Beside conventional treatment of HF, 4 targeted therapies including pharmacological prolactin blockade are being investigated. 5 Although half of patients will fully recover left ventricular systolic function, the clinical course of PPCM is highly variable. 6,7 Data from the Investigations of Pregnancy-Associated Cardiomyopathy (IPAC) recently assessed a 6% rate of death, heart transplantation, and left ventricular assist device (LVAD) implantation at 1 year in PPCM patients and more than 20% rate of persistent left ventricular (LV) dysfunction. 6 Baseline LVEF < 30%, baseline LV end-diastolic diameter (LVEDD) > 60mm, black ethnicity and post-partum diagnosis were correlated with poor prognosis. 6 Up to 10% of PPCM patients will require heart transplantation according to literature data. 6,8-10 Post-transplant prognosis for PPCM patients is at present still contradictory. 11-14 A higher incidence of rejection has been reported, particularly during the first year following transplantation, along with a lower graft survival. 13,14 Heart transplantation (HT) is however considered as a valuable option for PPCM patients presenting with HF unresponsive to maximal conventional treatment. The aim of this study is to compare all-cause mortality and transplant-related complications after HT for PPCM. Methods This is a retrospective single-center non-interventional study. Primary endpoint was all-cause mortality following heart transplantation (HT). Secondary endpoint was outcomes after HT including transplant-related complications (rejection, infection, cardiac allograft vasculopathy). All patients had single-center management with a consistent approach at both surgical and medical levels. Patient population A total of 1938 patients from whom 368 females were transplanted for severe HF in our institution. Fourteen patients met diagnosis criteria of PPCM. All our PPCM cases were ascertained with the most recent definition of the disease. 1 An extensive work-up was performed retrospectively for each 181