Peripartum Cardiomyopathy: Diagnostic and Prognostic Value of Cardiac Magnetic Resonance in the Acute Stage

Abstract

This study aimed to evaluate the diagnostic and prognostic value of cardiac magnetic resonance in acute peripartum cardiomyopathy (PPCM). A total of 17 patients with PPCM in the acute stage and 15 healthy controls were retrospectively analyzed regarding myocardial function, edema, late gadolinium enhancement (LGE), and T1 and T2 mappings (T1, T2). Echocardiographic follow-ups were performed. Functional recovery was defined as a left ventricular ejection fraction (LVEF) of ≥50%. Patients with PPCM displayed biventricular dysfunction with reduced myocardial strain parameters and left ventricular and atrial dilatation, as well as diffuse myocardial edema (T2 signal intensity ratio: 2.10 ± 0.34 vs. 1.58 ± 0.21, p < 0.001; T1: 1070 ± 51 ms vs. 980 ± 28 ms, p = 0.001; T2: 63 ± 5 ms vs. 53 ± 2 ms, p < 0.001). Visual myocardial edema was present in 10 patients (59%). LGE was positive in 2 patients (12%). A total of 13 patients (76%) showed full LVEF recovery. The absence of visual myocardial edema and impairment of strain parameters were associated with delayed LVEF recovery. Multivariable Cox regression analysis revealed global longitudinal strain as an independent prognostic factor for LVEF recovery. In conclusion, biventricular systolic dysfunction with diffuse myocardial edema seems to be present in acute PPCM. Myocardial edema and strain may have prognostic value for LVEF recovery.

Keywords: cardiac magnetic resonance imaging; heart failure; mapping; myocardial edema; peripartum cardiomyopathy; pregnancy; strain.

Figure 1

Graphs with individual plotted values show distribution of functional (A–F) and structural (G–I) cardiac MRI parameters in the control and the peripartum cardiomyopathy group (PPCM). Individual values are represented as single-colored dots. The horizontal lines show the mean values with error bars representing one standard deviation. p-Values were obtained using unpaired Student’s t-test. LV = left ventricular.

Figure 2

Line graphs show functional cardiac magnetic resonance parameters (A–D) at baseline (n = 6) and follow-up (n = 6). Individual values are represented by the dots at baseline and follow-up MRI. The connecting lines show the tendency of change in functional parameters over time. p-Values were obtained using paired Student’s t-test. LVEF = left ventricular ejection fraction, RVEF = right ventricular ejection fraction.

Figure 3

Representative example of cardiac magnetic resonance in a 32-year-old female with acute peripartum cardiomyopathy and recovery at follow-up after 2 months. Cine images (balanced steady-state free precession, b-SSFP) are oriented in horizontal long-axis view and at end systole and showed highly reduced left ventricular ejection fraction (35%) with global hypokinesia, left ventricular dilatation (left ventricular end-diastolic volume index: 118 mL/m²), and pericardial effusion (white arrows). Baseline fat-suppressed images (T2-weighted short TI inversion recovery, T2-STIR) at end diastole revealed extensive diffuse myocardial edema, which normalized at follow-up. No focal enhancement was identified on initial or follow-up late gadolinium enhancement (LGE) imaging. Quantitative mapping showed high global myocardial native T1 and T2 relaxation times at baseline MRI and normalization at follow-up.

Figure 4

Kaplan–Meier curves showing cumulative hazard functions for left ventricular function recovery over time. Curves are given for (A) visual myocardial edema, (B) global longitudinal strain, and (C) global circumferential strain at initial presentation.