Left bundle branch block and undesirable shape

[MrsEener]

Dr Fett,

In the stress echo I had yesterday and the one I had a year ago, they saw intermittant lbbb during exersize. I had 2 stress tests previously. One was before I ever got pregnant, but many years after I received 450mg/m2 doxorubicin. The other one was just a couple of weeks after being diagnosed 7 months postpartum with DCM with EF 30% and being on 2.5mg/day lisinopril for about a week. Neither of those previous stress tests showed lbbb. Can PPCM cause lbbb, or is it more likely caused by doxorubicin?

Also, I recall you writing in one thread that not taking a beta blocker can lead to an undesirable shape in a muscle, or something like that. I was only prescribed lisinopril. Should I point this out to my doctor and ask her about the shape of which muscle?

Thanks,
Bless you,
you're the best

[JAMESFETT]

PPCM and IDCM (Idiopathic Dilated Cardiomyopathy) can both cause LBBB. In both of these there is a focal (scattered and limited) inflammatory process in the heart, and if that process is in the right place, involving the left bundle (or for that matter anywhere in the conducting system of the heart) the result may be an abnormal EKG/ECG pattern and/or rhythm. I'm not very familiar with the effect of doxyrubicin toxicity on the heart, but that certainly would be a complicating factor, and I suppose that could also be responsible. The effect of beta-blocker in minimizing the undesirable remodeling shape of the heart is experienced in the early weeks and months following development of the dilated cardiomyopathy. With an EF of 60 percent now, I don't think it would be helpful or necessary, unless there are other indications.

JD

[MrsEener]

A followup question.

In your experience, do you think having preexisting lbbb or other similar problem makes it less likely to recover fully from PPCM?

[JAMESFETT]

No, I don't think the presence of LBBB means that one is less likely to recover from PPCM or inflammatory post-viral or non-viral dilated cardiomyopathy. I think it merely reflects that a certain area of the heart was affected by this patchy inflammatory process. Key to recovery is early treatment that stops the inflammatory process and preserves heart muscle cells (cardiomyocytes) that have not been destroyed. In the well-diagnosed, well-treated groups, everyone has a sufficient reserve of cardiomyocytes that she stays above the recovery threshold.

JD

[JAMESFETT]

P.S. There is also a group called "fulminant myocarditis" or "fulminant lymphocytic myocarditis" in whom the initial presentation is very severe and very rapid. Interestingly, the full recovery rate is these persons is very high, so if one can be brought through the acute illness, the outlook is excellent for full recovery. We don't know why some people go this "fulminant" route, but it can also happen in PPCM and IDCM. The "fulminant" group also tends to have higher plasma CRP levels, higher proinflammatory cytokine levels, more thickening of the heart wall, but less dilatation of the left ventricle.

JD

[MrsEener]

In the well-diagnosed, well-treated groups, everyone has a sufficient reserve of cardiomyocytes that she stays above the recovery threshold.

JD

Am I understanding you right? Anyone who develops PPCM and it is caught and treated early and properly will recover?

[JAMESFETT]

Of course there are no guarantees; but we have strong evidence that this is so. If only we can avoid delays in diagnosis and apply the best conventional heart failure treatment (diuretics, ACE-inhibitors, and beta-blockers) we will see a very large number of women recovering full function. Isn't it a matter of awareness on the part of mothers and their doctors? If one thinks about PPCM in that setting, the diagnosis is then very easy.

JD

[MrsEener]

I'm sorry to keep going on this. I really appreciate your answering my questions. That seems like such a fantastic assertion. So we really really really need to get the word out, huh?

Also, if this is the case, then why is there such hesitation to have post-PPCM pregnancies (in recovered women)? If the woman is monitored closely and any problems are caught right away and treated, she has an excellent chance of recovery.

[RobinaIII]

Hello,

I am new to the site and am thrilled to be here. What a wonderful group of women (and men), and the support that you offer one another is fantastic. I am glad to be part of the club. I need to play catch-up in terms of understanding this condition and all of the lingo, so please bear with me. I will share my personal story in a separate e-mail.

For now, I had a follow-up question for Dr. Fett. I recently read an article that said approximately 50% of women recover from PPCM. I suppose recovery consists of a 50% or above EF for a sustained period of time (including post PPCM pregnancy)?

Also, Dr. Fett, do you have a recommendation for a great PPCM cardiologist in the Dallas or Plano, Texas?

Thanks!

[JAMESFETT]

Attitudes are changing about subsequent pregnancy in women with a previous diagnosis of PPCM. What is fueling this change is the better treatment results leading to recovery of left ventricular systolic function to EF over 50 percent and the realization that subsequent pregnancy is well tolerated in this group of recovered women.

JDF

[JAMESFETT]

hello and welcome to RibinaIII. I am interested in learning more of your story. I'm sorry not to be aware of PPCM specialists in your area. The nearest that I know would be Dr. Elkayam in L.A., CA. Of course I am sure there are many excellent cardiologists in your area. I define recovery as reaching an EF of 50 percent above, with or without ACE-inhibitors and/or beta-blockers treatment. For purposes of assessing readiness for a subsequent pregnancy I believe the dobutamine stress echo is helpful in knowing more about reserve heart function. The 50 percent figure you give may represent a somewhat out-dated figure based on both optimum and non-optimum current treatment standards. I believe we will see higher figures than that for those women without diagnosis delays and whose treatment from the beginning include diuretics, beta-blockers, and ACE-inhibitors (or their substitute called ARB's). You may want to look at the thread at the beginning of this forum about frequently asked questions.

JD

[SerenaWelsh]

I can assist you in finding a specialist in Dallas and/or Plano. Please send me an e-mail to Serenawelsh@earthlink.net and I can get your info offline.

Thanks,

[JAMESFETT]

P.S. to Renee. In addition, there is a growing awareness that in the event there is going to be a relapse of PPCM in a recovered PPCM patient with subsequent pregnancy:

1)It is possible to monitor for early indicators of impending relapse and

2)Treatment instituted early in the case of relapse has a high success rate in stabilizing the relapse, permitting timely safe delivery and ongoing treatment.

JD