Peripartum cardiomyopathy presenting with predominant left ventricular diastolic dysfunction: efficacy of bromocriptine

Abstract

Management of patients with peripartum cardiomyopathy (PPCM) is still a major clinical problem, as only half of them or slightly more show complete recovery of left ventricular (LV) function despite conventional evidence-based treatment for heart failure. Recent observations suggested that bromocriptine might favor recovery of LV systolic function in patients with PPCM. However, no evidence exists regarding its effect on LV diastolic dysfunction, which is commonly observed in these patients. Tissue Doppler (TD) is an echocardiographic technique that provides unique information on LV diastolic performance. We report the case of a 37-year-old white woman with heart failure (NYHA class II), moderate LV systolic dysfunction (ejection fraction 35%), and severe LV diastolic dysfunction secondary to PPCM, who showed no improvement after 2 weeks of treatment with ramipril, bisoprolol, and furosemide. At 6-week followup after addition of bromocriptine, despite persistence of LV systolic dysfunction, normalization of LV diastolic function was shown by TD, together with improvement in functional status (NYHA I). At 18-month followup, the improvement in LV diastolic function was maintained, and normalization of systolic function was observed. This paper might support the clinical utility of bromocriptine in patients with PPCM by suggesting a potential benefit on LV diastolic dysfunction.

Figure 1

Echocardiographic indexes of left ventricular diastolic function. Standard Doppler of transmitral flow (a) and Tissue Doppler of left ventricular myocardial motion (b). The main indexes for the assessment of left ventricular diastolic function are (1) the peak early diastolic myocardial velocity E′, which is an index of LV relaxation; (2) the ratio between the peak early diastolic velocity of transmitral flow and E′ (E/E′ ratio), which is an index of left ventricular filling pressure.

Figure 2

Gadolinium-enhanced cardiac magnetic resonance imaging. Two-chamber (a) and four-chamber (b) views obtained by magnetic resonance imaging after enhancement by gadolinium. In addition to left ventricular enlargement, the dark appearance of the left ventricular myocardium (arrows) indicated lack of delayed enhancement, suggesting that no fibrosis or other abnormalities in myocardial architecture were present. LV = left ventricle; RV = right ventricle; LA = left atrium; RA = right atrium.

Figure 3

Left ventricular diastolic function at baseline and at the 6-week followup. Left column: Baseline examination. Doppler pattern of transmitral flow (a), Tissue Doppler pattern of left ventricular (LV) motion recorded at the junction with the septal mitral annulus (b), and color Tissue Doppler velocities of multiple LV myocardial segments ((c): yellow, basal septum; turquoise, middle septum; red, basal lateral; green, middle lateral). Severe reduction of peak early diastolic myocardial velocity (E_m) and considerable early diastolic dyssynchrony between segments (dotted arrow) were present. Right column: corresponding images obtained after 6 weeks of therapy with bromocriptine. Transmitral Doppler pattern was substantially unchanged (d), whereas a considerable increase in E′ (e) and a reduction in early diastolic dyssynchrony ((f), dotted arrow) were observed. Also note the different velocity scales between (c) and (f), and the increase in early diastolic velocities of all myocardial segments at 6-week followup compared to baseline. A = peak late diastolic transmitral flow; A′ = peak late diastolic myocardial velocity; E = peak early diastolic transmitral flow; S′ = peak systolic myocardial velocity.