Dr. Fett - Charlotte NC PPCM Cardiologist

[ncwahoos]

Dr. Fett,

I am 35 and was diagnosed with PPCM on 8/20, one week after the birth of my third child. I have an EF of 50-55 and a leaky mitral valve and enlarged heart. I am currently on Coreg 3.125 twice a day, Accupril 5 mg daily, Lasix, and potassium. I was referred to the cardiologist on staff during my stay in the hospital and was wondering if you have information on PPCM specialists in the Charlotte, NC area as I would like to make sure the cardiologist I am seeing is most experienced and is the best qualified to treat my condition.

Thanks,
Stephanie

[JAMESFETT]

Hi Stephanie. I don't know any cardiologists in Charlotte, NC, but the triangle of Duke, Raleigh and Chapel Hill is well known for its fine medical resources, and I'm sure you have a lot of good cardiologists in that area. For a new diagnosis of PPCM your EF of 50 to 55 is surprisingly good, perhaps it was lower initially? An enlarged left ventricle in PPCM is the usual finding, since PPCM is a "dilated cardiomyopathy" and leakage across the mitral valve is very common, and not in itself a problem. Just need to be sure there is no primary valve disease leading to the leakage and heart enlargement. That can be determined by echo Doppler. Usually in PPCM with an EF of 50 to 55, there is no significant leakage across the mitral valve, so again, I want you and your doctors to be certain your diagnosis is not "valvular heart disease." By definitioin, if there is any other explanation for heart failure [and EF 50-55 would be borderline function, at worst] [and initial at-diagnosis EF 50-55 would not meet the echo criteria added to the original definition of PPCM to meet criteria for diagnosis of PPCM], then PPCM can no longer be the diagnosis. I'm not sure I made that very clear? You are on the two best medications for heart failure and PPCM--and of course the lasix is for any excess fluid.

[ncwahoos]

Dr. Fett,

I saw the cardiologist yesterday and got some more information from my echo. They still say the diagnosis is PPCM. They took me off the Lasix and Potassium as the lab work and physical exam showed no further evidence of fluid retention. Additionally, I was told I have a moderate leak in my tricuspid valve and a moderate to moderately severe regurgitation in the mitral valve. My left ventricle is mildly enlarged. I do not have a third heart sound. All of this is very confusing to me as I don't understand how my ejection fraction could be normal (50-55 percent) but I could still have had congestive heart failure. Prior to two days after the birth of my daughter I had no symptoms whatsoever (blood pressure was normal and low in fact, no heart issues, etc.) Are these symptoms unusual?

Is it possible for valves to heal themselves over time? The information I have read on moderate to severe valve issues is concerning to me.

Thanks,
Stephanie

[JAMESFETT]

Thanks, Stephanie, for the follow-up. Your left ventricle is enlarged, that can explain both the mitral and tricuspid regurgitation. From what you report that your cardiologist told you, I would accept his/her confirmation of PPCM as the diagnosis, meaning that there is no organic, structural abnormality of the valve, and hence you do not have "valvular heart disease". The regurgitation can accompany PPCM, and be harmless in and of itself, and usually decreases and/or disappears as the heart size returns towards normal. We do follow-up echos at 6 months, and I anticipate you will continue to improve. It makes great sense to discontinue the lasix and potassium, while continuing the ACE-I and B-B. I think you can feel reassured that things are moving in a good direction, and I anticipate you will have recovery from PPCM. I think you are in good hands, and that you can follow along with confidence. At any time I'd be happy to learn how things are going. It is possible to have the EF at 50-55, and still not have a completely normal left ventricle--with time that will come, I think.

JD

[ncwahoos]

Dr Fett,

I can't thank you enough for the information you provide on this board. I am trying to do everything I can to get better so I hope to see results in October with my next echocardiogram which I will be sure to share. So far I have been successful with the discontinuation of the Lasix and Potassium. Since my last visit, I am now being followed by the Heart Failure and Transplant group at Sanger Clinic in Charlotte. It is part of the Carolinas Medical Center organization. My doctor was switched as well when I was reassigned to this group and the new one seems to have more experience in the area of PPCM than the cardiologist to whom I was originally assigned in the hospital; although, none have as much experience as you given that this occurs so infrequently in this area. My OB says they see max of two cases of this a year from a practice that averages over 1500 deliveries a year.

Thanks again,
Stephanie

[JAMESFETT]

Thanks, Stephanie. You won't need a transplant, but it is good for you to be with that heart failure unit. Their frequency of 1 case of PPCM per year per 750 deliveries, is about 4 or 5 times greater than the all-USA incidence, and of course is higher because they are a special referral unit. I'm glad you're doing so well, don't be hasty to go off the ACE-I and B-B.

JD

[ncwahoos]

I definitely am not in a rush to go off the remaining medication I am on (Accupril and Coreg). In fact, they said I will likely remain on Coreg indefinitely as they have seen many cases of regression in their heart failure patients that have stopped taking it (albeit the regression has occurred over an extended period of time, but still they feel strongly that Coreg should be continued to retain the benefits of any heart function improvement). I would be interested in your thoughts on that as well as I know many on this board have discontinued medicines completely after recovering. I think the Accupril is something they will consider taking me off of if I improve over time, but all that remains to be seen with the next set of tests in October.

Stephanie

[JAMESFETT]

Stephanie, that's a good plan. No one knows for sure when to discontinue treatment. Staying on the B-B (carvedilol) for prolonged time is a good idea, and phasing out the ACE-I before the B-B, but still a long ways down the road (i.e. at least a year after diagnosis) is also a good idea. 15 Inotropic contractile reserve during dobutamine stress echocardiography has also been shown to correlate with subsequent recovery in PPCM patients tested initially and at follow-up.

[1. Lampert MB, Lynn Weinert BS, Hibbard J, Korcarz C, Lindheimer M, Lang RM. Contractile reserve in patients with peripartum cardiomyopathy and recovered left ventricular function. Am J Obstet Gynecol 1997;176:189-95.

2.Dorbala S, Brozena S, Zeb S, Galatro K, Homel P, Ren JF, Chaudhry FA. Risk stratification of women with peripartum cardiomyopathy at initial presentation: a dobutamine stress echcardiography study. J Am Soc Echocardiogr 2005;18:45-8.]

JD