Dr. Fett

[miracle baby]

I Have A Family History Of Heart Problems .when I Went In With Shortness Of Breath And The Xray Showed My Heart Was Enlarge With Fluid On My Lungs Shouldnt He Of Sent Me To The Hospital
And Took The Baby That Day Because My Blood Pressure Was High.

[JAMESFETT]

I'm so sorry your critical situation was unrecognized at that time. Usual procedures would be urgent investigation and treatment. Immediate echocardiography would be indicated. With that the diagnosis of dilated cardiomyopathy (for you, PPCM) would have been identified. Treatment with diuretics, ACE-inhibitors, and at some point beta-blockers would have followed, and you would have been spared later emergency care with intubation and respirator. Having said that I don't want to dwell on what is past, and I am extremely grateful you are now making excellent progress and have survived. If you want to learn about another USA PPCM patient whose diagnosis was even more unrecognized and delayed so that she was being considered for liver transplant, until an echocardiogram was finally done with recognition of PPCM, and she subsequently recovered completely, then see Fussell et al, "case of fluminant hepatic failure due to unrecognized peripartum cardiomyopathy. Critical Care Medicine 2005;33:891-93. Many of us are working as hard as we can to tell the story about PPCM, so that physicians will diagnose it early.

JD

[JAMESFETT]

P.S. My letter in response to the article in Critical Care Medicine follows in Vol 33, No 8, page 1892:

Unrecognized Peripartum Cardiomyopathy:
Thank you for your recent case report of unrecognized peripartum cardiomyopathy (PPCM) presenting as fulminant liver failure secondary to passive congestion.1 The authors’ report of this case is particularly important because it reminds us of the need for early consideration of PPCM in any peripartum patient. Fortunately, this patient both survived and recovered, a remarkable characteristic of this unique form of cardiomyopathy. The PPCM Project of Haiti has documented the highest incidence of PPCM in the world2,3 and in the process has shown the ability of PPCM mothers to continue to recover long after the initial 6 months post-diagnosis stage (contrary to the commonly-held belief). The frequent occurrence of PPCM in Haiti has sensitized our medical providers to think of PPCM in any late partum or post-partum patient with suggestive signs/symptoms of heart failure (HF), and to do an echocardiogram as the most essential diagnostic test early in the course, since timely diagnosis is associated with reduced mortality and morbidity. We have documented a lymphocytic myocarditis or inflammatory cardiomyopathy in autopsy tissue from some of our patients, but do not have the capability of performing endomyocardial biopsy. If we did, we would biopsy those who are not improving in the initial days and weeks, because one of the most essential tests waiting to be carried out in PPCM is the application of polymerase chain reaction technology to heart tissue in a search for viral genômes. Fussell at al correctly cite the high frequency of myocarditis in PPCM patients studied by Midei4 but it is incorrect to attribute the myocarditis to viral infection at this time.
In the article cited, Midei states, “The etiology of myocarditis resulting in PPCM is not known. It may be viral, drug, toxin, or immune in origin.” The same applies a decade later as reported by Felker et al,5 from the same institution. Our ongoing studies of PPCM patients suggest promising new areas to investigate the pathophysiology of PPCM.6-8 These studies have the potential to lead to important new therapies such as plasmaphoresis, immunoadsorption, and immunomodulatory medications.

--James D. Fett, MD


References:
1. Fussell KM, Awad JA, Ware LB. Case of fulminant hepatic failure due to unrecognized peripartum cardiomyopathy. Crit Care Med Apr 2005; 33:891-93.
2. Fett JD, Dowell DE, Carraway RD, King ME, Pierre R. Peripartum cardiomyopathy in the Hospital Albert Schweitzer District of Haiti. Am J Obstet Gyn 2002;186:1005-10.
3. Fett JD, Dowell DL, Carraway RD, Sundstrom JB, Ansari AA. 100 cases of peripartum cardiomyopathy…and counting: What is going on? Int J Cardiol 2004;97 (3): 571-73.
4. Midei Mg, Dement SH, Feldman AM, et al, Peripartum myocarditis and cardiomyopathy. Circulation 1990;81:922-28.
5. Felker GM, Jaeger CJ, Klodas E, et al, Myocarditis and long-term survival in peripartum cardiomyopathy. Am Heart J 2000;140:785-91.
6. Ansari AA, Fett JD, Carraway RD, Mayne AE, Onlamoon M, Sundstrom JB. Autoimmune mechanisms as the basis for human peripartum cardiomyopathy. Clin Rev Allergy Immunol 2002(Dec); 23:289-312.
7. Ellis JE, Ansari AA, Fett JD, Carraway RD, Randall HW, Mosunjac MI, Sundstrom JB. Inhibition of progenitor dendritic cell maturation by plasma from patients with peripartum cardiomyopathy: role in pregnancy-associated heart disease. J Clin Devel Immunology 2005 (In press).
8. Warraich RS, Fett JD, Damasceno A, Carraway RD, Sundrom JB,Arif J, Essop R, Ansari AA,Yacoub MH, Silwa K. Impact of Pregnancy related heart failure on humoral immunity: clinical relevance of G3-subclass Igs in peripartum cardiomyopathy. Am Heart J 2005 (In press).

[Kelly]

My question is kind of along the same lines. I was diagnosed with a molar pregnancy at 18 weeks and was sent to the hospital to get a chest x-ray to check for the spread of molar tissue. With that x-ray, they noticed the fluid on the lungs and admitted me so that they could clear up the "pnemonia" with anit-biotics before my D&C. My symptoms were high BP, couldn't breath well, couldn't sleep lying down, coughs that produced a lot of phlegm with blood.... At this point should someone have suspected PPCM?? And if it had been dx before the D&C, would anything have been done differently?

I was also diagnosed with HELLP syndrome after being admitted which caused them to move the D&C up as soon as possible.

[JAMESFETT]

PPCM associated with molar pregnancy has been described in the medical literature, but to link the two is more difficult because the traditional criteria for diagnosis of PPCM include "the first appearance of heart failure in the last month (8th or 9th) of pregnancy or within 5 months after delivery." "Fluid on the lungs" can be seen with pneumonia as well, so the differential diagnosis includes both heart failure and pneumonia. In this day, we have the blood B-type natriuretic peptide (BNP) to help distinguish lung-related problems to heart-related problems, and an elevated blood BNP will immediately cause one to focus on the heart, at which time an echocardiogram is indicated. In anyone with dyspnea (difficulty breathing) a blood BNP should be determined to help differentiate between lung problems and heart problems.

JD