ABC | Volume 110, Nº2, February 2018

Original Article Bouabdallaoui et al Heart Transplantation for PPCM Arq Bras Cardiol. 2018; 110(2):181-187 Discussion In this retrospective single-center study, we assessed post‑transplant outcomes in a population of patients transplanted for severe HF in the setting of peripartum cardiomyopathy. Median follow-up was 7.7 years. We demonstrate upon our population that post-transplant mortality is significantly lower in patients transplanted for PPCM. Patients transplanted for PPCM did not display a significantly higher rate of transplant-related complications compared with control subjects matched for age and transplantation period. Pre-transplant characteristics In the pre-transplant setting, we significantly used more inotropes at the time of HT in PPCM patients compared with control subjects. The frequent need of medical intensive cardiovascular support in PPCM patients awaiting heart transplantation has also been demonstrated by others. 13 Importantly, potential deleterious cellular alterations related to Dobutamine have recently been pointed in PPCM patients, 21 and recent guidelines recommend a cautious use of inotropes for critically-ill PPCM patients. 22 Data related to MCS in the management of PPCM patients are scarce. 23, 24 It seems however that MCS is an option for patients who deteriorate despite maximal therapy, in a strategy of bridge to transplantation or to recovery. 6,22-25 Noticeably, one major concern in the setting of long-term MCS in PPCM patients relates to a possibly higher risk of thrombotic complications in a prothrombotic condition such as the peripartum period. 26 Medical management of HF might be considered as non‑optimal in our population, particularly among PPCM patients, as only one half received beta-blockers and ACE inhibitors. Importantly, under-treated patients were, in both groups, those requiring inotropic and mechanical circulatory support. Seven percent (7%) of patients had CRT/ICD implantation. Recent data suggest that CRT is crucial in the management of PPCM patients presenting with persistent systolic dysfunction. It has indeed been demonstrated a rapid and significant LV recovery under CRT in PPCM patients with severe systolic dysfunction despite optimal medical therapy. 27 Patients Outcomes after Heart Transplantation We assessed post-transplant outcomes in patients transplanted for PPCM. Again, we demonstrated a significantly lower post-transplant all-cause mortality in patients transplanted for PPCM, with a similar rate of transplant-related complications as compared with control subjects. Data on long-term outcomes after HT for PPCM are contradictory, reporting either favorable outcomes, 11 or higher rejection rates and poorer outcomes. 12-14 Current practice is however favorable to HT for PPCM. As we did, a long-term survey of a small cohort of patients transplanted for PPCM has also shown favorable outcomes. 23 Limitations The major limitation of our study is the small number of patients, prohibiting definitive conclusions. We arbitrarily adjudicated rejection in a binary way (present: yes, or no), which might therefore be considered as simplistic and of limited value. Conclusion We assessed long-term post-transplant outcomes in the setting of PPCM. Upon the studied population, we demonstrate a significantly lower long-term post-transplant mortality in patients transplanted for PPCM, with a similar rate of transplant-related complications as compared with control subjects. We show that heart transplantation for PPCM patients who did not significantly recover under maximal medical treatment remains appropriate. The overall impact of heart transplantation for PPCM is yet to be determined at a larger scale in well characterized population. Author contributions Conception and design of the research: Bouabdallaoui N; Acquisition of data: Bouabdallaoui N, Demondion P; Analysis and interpretation of the data: Marechaux S; Statistical analysis: Marechaux S; Writing of the manuscript: Bouabdallaoui N; Critical revision of the manuscript for intellectual content: Varnous S, Lebreton G, Mouquet F; Supervision: Leprince P. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. Ethics approval and consent to participate This article does not contain any studies with human participants or animals performed by any of the authors. 185