Right Ventricular Dysfunction and Adverse Clinical Outcomes in Peripartum Cardiomyopathy

Abstract

Background

The prognostic significance of right ventricular (RV) dysfunction in peripartum cardiomyopathy (PPCM) remains inconsistent across studies.

Objectives

This study aimed to evaluate the association between RV dysfunction at diagnosis and likelihood of left ventricular (LV) systolic function recovery and major adverse outcomes in PPCM.

Methods

We conducted a meta-analysis to identify studies with assessment of RV function, major adverse outcomes, and LV systolic function recovery. RV dysfunction was defined using echocardiographic parameters such as tricuspid annular plane systolic excursion <16 mm, fractional area change <35%, S’ <10 cm/s, or RV ejection fraction <45% on cardiac magnetic resonance imaging. The primary outcomes were LV systolic function recovery (LV ejection fraction ≥50%) and major adverse clinical outcomes (LV assist device, recurrent heart failure hospitalization, orthotopic heart transplantation, or death). Pooled ORs and 95% CIs were calculated using random-effect models.

Results

Five studies (N = 472, n = 117 with RV dysfunction; 1,212 person-years of follow-up) met criteria. Participants had a mean age of 32 ± 7 years. After a median follow-up of 25 months (Q1-Q3: 6.8-36.9), RV dysfunction in PPCM was significantly associated with a decreased likelihood of LV systolic function recovery (OR: 0.39; 95% CI: 0.21-0.71; P < 0.001) compared to those without RV dysfunction. With a median follow-up of 32.9 months (Q1-Q3: 15.3-42.6), those with RV dysfunction were 4 times more likely to experience adverse clinical outcomes (OR: 4.19; 95% CI: 2.23-7.85; P < 0.001).

Conclusions

Our findings suggest that RV dysfunction at diagnosis is associated with a higher risk of major adverse outcomes and a lower likelihood of LV function recovery in PPCM.

Central Illustration

Peripartum cardiomyopathy (PPCM) is characterized by left ventricular (LV) systolic dysfunction and symptoms of heart failure that occur during the late stages of pregnancy and the early postpartum period.¹ PPCM is a rare form of cardiac failure with an unknown etiology, associated with high morbidity and mortality among young women.² Right ventricular (RV) dysfunction is found in nearly half of women with PPCM and is commonly observed across various cardiovascular conditions, where it plays a significant role in determining patient prognosis.3, 4, 5 The prevalence of RV dysfunction in PPCM ranges from 40% to 88% in most cohorts.^6,7 In a study by Blauwet et al,⁷ RV systolic dysfunction, as defined by echocardiographic fractional area change (FAC <35%), correlated with subsequent lack of LV systolic function recovery and major clinical outcomes in PPCM. Others have found that those with RV systolic dysfunction were at increased risk of hospitalization for heart failure and mortality.³

However, studies have been inconsistent on the prognostic role of RV dysfunction and outcomes in PPCM. Although some have found that RV dysfunction is associated with major clinical outcomes such as lack of LV systolic fraction recovery and higher rates of adverse cardiovascular events in PPCM, other studies suggest no association between RV dysfunction and outcomes in PPCM.7, 8, 9, 10 It remains unclear whether RV dysfunction at the time of diagnosis is associated with major adverse clinical outcomes or the rate of LV systolic function recovery in the long term, which has significant implications for prognosis, clinical management, and risk stratification.¹¹ This meta-analysis aims to examine the prognostic role of RV dysfunction in predicting adverse clinical outcomes and the likelihood of LV systolic function recovery.

Methods

Study selection and eligibility criteria

Studies were eligible for inclusion if the population consisted of women with PPCM, a follow-up time of ≥6 months, and available data on LV systolic function recovery and adverse clinical outcomes stratified by RV function. RV dysfunction was defined using echocardiography for most studies: tricuspid annular plane systolic excursion (<16 mm), FAC (<35%), or Doppler tissue imaging-derived tricuspid annular systolic velocity (S’ <10 cm/s), and degree of RV dilatation. One study (Haghikia et al) utilized cardiac magnetic resonance and defined RV dysfunction as RV ejection fraction <45%.⁸ LV global systolic function recovery was defined as a LV ejection fraction ≥50% on follow-up echocardiograms. Adverse clinical outcomes included the occurrence of one or more of the following: implantation of a LV assist device, cardiac transplantation, recurrent hospitalization for heart failure, or death. Studies were excluded if the study population did not have women with PPCM or adequate follow-up or if outcomes or RV function were not reported. In cases where several studies from the same cohort were available, data from the study with the latest follow-up were selected. We excluded literature reviews, cross-sectional studies, preclinical studies, animal studies, and effect estimates from conference abstracts when a full published study was not available. We conducted the meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Two independent reviewers screened and extracted data from full-text articles, and Cohen kappa was calculated to determine interrater reliability (Supplemental Figure 1). We used a combination of subject headings and search terms related to PPCM, RV function, LV systolic function recovery, clinical outcomes, and mortality as defined below.

Search strategy

We performed a literature search for all relevant publications using the following databases: PubMed, Ovid MEDLINE, Ovid Embase, Web of Science, and Cochrane Library up to August 2024. We used the following terms [All Fields] for PubMed: “Peripartum Cardiomyopathy AND Right Ventricular Function; Peripartum Cardiomyopathy AND Outcomes; Peripartum Cardiomyopathy AND Right Ventricular Dysfunction; Peripartum Cardiomyopathy AND Right Heart Failure; Peripartum Cardiomyopathy AND Hospitalization; Peripartum Cardiomyopathy AND Mortality; Pregnancy-Associated Cardiomyopathy AND Right Ventricular Function; Pregnancy-Associated Cardiomyopathy AND Outcomes; Pregnancy-Associated Cardiomyopathy AND Right Ventricular Dysfunction; Pregnancy-Associated Cardiomyopathy AND Right Heart Failure; Pregnancy-Associated Cardiomyopathy AND Hospitalization; Pregnancy-Associated Cardiomyopathy AND Mortality; Right Ventricular Dysfunction AND Outcomes AND Peripartum Cardiomyopathy; Right Ventricular Dysfunction AND Hospitalization AND Peripartum Cardiomyopathy; Right Ventricular Dysfunction AND Mortality AND Peripartum Cardiomyopathy; Right Ventricular Dysfunction AND Outcomes AND Pregnancy-Associated Cardiomyopathy; Right Ventricular Dysfunction AND Hospitalization AND Pregnancy-Associated Cardiomyopathy; Right Ventricular Dysfunction AND Mortality AND Pregnancy-Associated Cardiomyopathy” (Supplemental Table 1). These search terms were also used for MEDLINE, EMBASE, Web of Science, and Cochrane Library. To identify any additional studies not captured by these searches, we also hand-searched reference lists of primary and review articles. In addition, we searched proceedings of relevant societies (American Heart Association, American College of Cardiology, and European Society of Cardiology). We also contacted corresponding authors of studies in an effort to obtain data stratified by RV function when such data were not available in the published manuscript.

Data extraction

We obtained the full-text articles of the relevant studies and conducted a detailed review to ensure that they met the inclusion criteria for the meta-analysis. Using a standardized data extraction form to collect relevant data from each of the included studies, we extracted information on sample size, follow-up time, patient characteristics, and outcome measures. The following variables were extracted from each study using a standardized template: title, authors, year of publication, geographic location, age, race, body mass index, follow-up time, sample size, number of participants, covariates adjusted for in the multivariable analysis, LV systolic recovery, and cardiovascular outcomes. The variable extraction was performed independently by 2 reviewers and cross-checked. This meta-analysis was conducted using published data from completed studies. No new data were collected and no identifying patient information was used; thus, institutional review board approval and informed consent were not required in accordance with institutional and international guidelines.

Statistical analysis

Descriptive statistics for pooled data such as year of publication, sample size, and follow-up period are shown. The studies were evaluated with regard to similarity of baseline patient characteristics, methods, and duration of follow-up. Due to variation in the assessment methods for RV function and outcomes, random-effects models were used to synthesize the weighted pooled OR with 95% CIs. The number of major adverse clinical outcomes was defined among patients with RV dysfunction compared to those without RV dysfunction.

Using the meta-analysis suite of commands in Stata, we generated forest plots and determined the group-specific and overall I² statistic. We used the Cochran Q test and the I² statistic to evaluate for heterogeneity between studies. The I² was calculated using Stata as follows: I² = Q − (k−1)/Q × 100%, where k is the number of studies, and k-1 is the degrees of freedom. We predefined high heterogeneity as an I² statistic >50%. Random-effect models were used for all analyses, despite the I² <50%, given the heterogeneity of RV function methods and outcomes assessment across the studies. We estimated ORs with 95% CIs for LV systolic function recovery and major adverse clinical outcomes. Additionally, we conducted a meta-regression to assess the association of LV recovery and major adverse clinical outcomes while adjusting for study-level covariates, including sample size and mean participant age.

Quality assessment and risk of bias

To assess the overall quality of evidence, we used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework developed by the GRADE working group.^12,13 This included the following aspects: overall risk of bias (from the QUIPS–Quality in Prognostic Studies tool), degree of imprecision, consistency of results, potential for publication bias, and extent of indirectness (Supplemental Table 2). We used the QUIPS (Quality in Prognosis Studies) tool to assess the risk of bias and internal validity of each study included in the meta-analysis. The QUIPS tool evaluates 6 domains of potential bias relevant to prognostic factor research: study participation, study attrition, prognostic factor measurement, outcome measurement, study confounding, and statistical analysis and reporting (Supplemental Table 3). To assess for publication bias, we inspected funnel plots and performed the Egger regression test using the metafunnel and metabias commands in Stata. All analyses were performed using Stata 17.0 (StataCorp); all tests were 2-sided, and a P value <0.05 was considered statistically significant.

Results

A total of 5 studies involving 472 participants (1,212 person-years of follow-up) met criteria for inclusion. LV systolic function recovery was reported in 4 studies (n = 387), and major adverse clinical outcomes were reported in 4 studies (n = 438) (Table 1, Central Illustration). Participants had an average age of 31.5 ± 6.5 years, a body mass index of 29.3 ± 5.8 kg/m², and 39% were of African descent. Obstetric history revealed a median gravidity of 2 (Q1-Q3: 1-5) and parity of 2 (1-4), with a 19% prevalence of preeclampsia. Additionally, 29% had a history of hypertension prior to pregnancy, 12% had diabetes mellitus, and 31% reported previous tobacco use (Table 2).

Table 1.

Baseline Characteristics of Individual Studies

First Author, Year	N	Patients With RV Dysfunction	Study Type	Study Location	RV Dysfunction Definition	Outcomes	Follow-Up	Risk Predictors
Peters et al, 20189	53	21	Single-center retrospective cohort study	Philadelphia, PA, USA	Echocardiographic qualitative grading assessment of RV function and comparison with right heart catheterization	Severe LVEF <30%, LVAD, cardiac transplantation, death	Median (IQR): 3.6 (1.4-7.3) years	HRs (95% CI) Univariable analyses: LV ejection fraction <30% and moderate-to-severe RVD associated with outcome Multivariable model: only moderate-to-severe RVD was independently associated with the outcome
Pacheco et al, 202211	67	18	Multicenter retrospective cohort study	Quebec, Canada	Echocardiographic parameters: TAPSE, FAC, S’, or degree of RV dilatation	Mechanical support and a combined endpoint of hospitalization for heart failure, cardiac transplant, or death	25 months	Univariate analysis for predictors of heart failure, cardiac transplant, or death Age African American Use of bromocriptine RV dysfunction RV dilatation (mild and more) LVEDD at diagnosis LVEF at diagnosis
Haghikia et al, 20158	34	12	Multicenter prospective study	Hannover, Germany	Standardized cardiac magnetic resonance (left and right ventricular mass and volumes, systolic function, presence of myocardial edema, and fibrosis/necrosis)	LVEF ≤35%; LV recovery = LVEF ≥55%,	5 months	Not reported
Blauwet et al, 20167	100	21	Multicenter prospective study	USA (30 locations)	Echocardiographic assessment: RV FAC, EDA, ESA, and global longitudinal strain	LV recovery was defined as LVEF ≥50% on last echocardiographic assessment	1 year	Univariate analysis for lack of LV recovery: Age Black race LVEF, % LV EDD, mm RV FAC RV EDA RV ESA RV free wall strain RV global strain TAPSE
Imran et al, 202415	229	50	Multicenter cohort study	Boston, MA, USA	Echocardiographic parameters: TAPSE (<16 mm), S’ (<10 cm/s), or global visual assessment	Adverse composite outcome (adverse cardiovascular events and LV systolic function recovery)	3.4 years	Age Black of African descent Body mass index Gravidity Parity Tobacco use (current or former) Preeclampsia history Hypertension Diabetes mellitus Family history of cardiomyopathy Gestational age

EDA = end diastolic area; EDD = end diastolic dimension; ESA = end systolic area; FAC = fractional area change; LV = left ventricular; LVAD = left ventricular assist device; LVEF = left ventricular ejection fraction; RV = right ventricular; RVD = right ventricular dysfunction; TAPSE = tricuspid annular plane systolic excursion.

Central Illustration.

Prognostic Impact of Right Ventricular Dysfunction in Peripartum Cardiomyopathy

In this meta-analysis (n = 472 participants, 1,212 person-years of follow-up), RV dysfunction at diagnosis was associated with lower odds of LV systolic function recovery and higher risk of major adverse clinical outcomes, highlighting its importance as a prognostic marker in peripartum cardiomyopathy. LV = left ventricular; RV = right ventricular.

Table 2.

Baseline Demographics of Participants in the Individual Studies

	Peters et al, 20189	Pacheco et al, 202211	Haghikia et al, 20158	Blauwet et al, 20167	Imran et al, 202415
N	53	67	34	100	229
Age, y, mean (SD)	31 (7.6)	30 (7)	34 (5)	30 (6)	32.4 (6.7)
Race, Black, n (%)	40 (75)	17 (26)		30 (30)	63 (28)
Body mass index, kg/m2 mean (SD)	30.0 (4.3)		27 (5)		31 (8)
Obstetric history, median (IQR)
Gravity	3 (1-5)		1 (1-5)	3 (1-10)	2 (1-3)
Parity	2 (1-4)		1 (1-4)	2 (1-6)	1 (1-2)
Multiparity, n (%)		38 (62)
Preeclampsia, n (%)		16 (24)	4 (11)		44 (19)
Medical history, n (%)
Diabetes mellitus	14 (26)	8 (12)		11 (11)	20 (8.7)
Hypertension	32 (60)	10 (15)	9 (26)	45 (45)	45 (20)
Hyperlipidemia	15 (28)	2 (3)	4 (12)
Tobacco use		16 (25)	18 (53)		56 (24)

In all, there were 46 patients with RV dysfunction at diagnosis who developed major adverse outcomes and 50 patients with normal RV function who developed major adverse clinical outcomes. After a median follow-up of 18.5 months (Q1-Q3: 6.8-36.9), RV dysfunction in PPCM was found to be significantly associated with a decreased likelihood of LV systolic function recovery (OR: 0.39; 95% CI: 0.21-0.71; P < 0.001; I² = 0.00%) as compared to those without RV dysfunction at the time of diagnosis (Figure 1). With a median follow-up of 32.9 months (Q1-Q3: 15.3-42.6), women with PPCM who had RV dysfunction on presentation were 4.2 times more likely to experience major adverse clinical outcomes (OR: 4.19; 95% CI: 2.23-7.85; P < 0.001; I² = 0.00%) compared to those without RV dysfunction (Figure 2). The heterogeneity markers were low, with an I² near 0% and an H² of 1.00, suggesting no significant variability in the included studies. Furthermore, meta-regression models examining study-level covariates indicated that differences in study sample size and mean participant age did not have statistically significant associations with either LV systolic function recovery or major adverse clinical outcomes (Table 3, Table 4).

Figure 1.

Forest Plot: Right Ventricular Dysfunction and Long-Term Left Ventricular Systolic Function Recovery

This forest plot demonstrates the odds of long-term left ventricular systolic function recovery in patients with peripartum cardiomyopathy and right ventricular dysfunction at diagnosis. ORs with 95% CIs are shown, with each square representing study weight. REML = restricted/residual maximum likelihood.

Figure 2.

Forest Plot: Right Ventricular Dysfunction and Major Adverse Clinical Outcomes

This forest plot demonstrates the odds of major adverse clinical outcomes in patients with peripartum cardiomyopathy and right ventricular dysfunction at diagnosis. ORs with 95% CIs are shown, with each square representing study weight. REML = restricted/residual maximum likelihood.

Table 3.

Meta-Regression on Association of Sample Size, Mean Study Age, and LV Systolic Function Recovery (4 Studies)

	β Coefficient (95% CI)	P Value
Study sample size	0.001 (−0.006 to 0.009)	0.71
Mean study age	−0.05 (−0.56 to 0.45)	0.84

LV = left ventricular.

Table 4.

Meta-Regression on Association of Sample Size, Mean Study Age, and Major Adverse Clinical Outcomes (4 Studies)

	β Coefficient (95% CI)	P Value
Study sample size	−0.0001 (−0.02 to 0.016)	0.99
Mean study age	−0.17 (−1.43 to 1.09)	0.79

Quality assessment and risk of bias

The QUIPS and GRADE assessments were performed independently by 2 reviewers. Utilizing the QUIPS tool, most studies included information from cohort studies and were found to exhibit a low to moderate risk of bias. We used the GRADE framework as utilized by the GRADE working group to evaluate the certainty of the evidence. Our assessment revealed a moderate to high certainty supporting the prognostic value of RV dysfunction in PPCM for predicting LV systolic recovery and adverse clinical outcomes. The funnel plot and Egger test of LV systolic recovery had no small-study effects (P = 0.80), indicating low concern for publication bias (Figure 3). Additionally, the funnel plot and Egger test of clinical adverse outcomes also revealed no small-study effects (P = 0.21), indicating low risk of publication bias (Figure 4). However, funnel plots may be less reliable when a meta-analysis includes a small number of studies. To mitigate this, we present random-effects models instead of fixed-effects models to provide more conservative estimates.

Figure 3.

Funnel Plot: Left Ventricular Systolic Function Recovery

This funnel plot evaluates publication bias among studies evaluating the association between right ventricular dysfunction at diagnosis and LV systolic function recovery in peripartum cardiomyopathy. The distribution of studies is overall symmetrical, suggesting minimal publication bias. Egger test P = 0.80. LV = left ventricular.

Figure 4.

Funnel Plot: Major Adverse Clinical Outcomes

This funnel plot evaluates publication bias among studies on the association between right ventricular dysfunction at diagnosis and major adverse clinical outcomes in peripartum cardiomyopathy. The plot demonstrates a generally symmetric pattern, suggesting a low likelihood of small-study effects. Egger test P = 0.20.

Discussion

Although prior studies have evaluated the prognostic value of RV dysfunction in PPCM, existing data are not consistent.7, 8, 9, 10^,14 To our knowledge, this is the first meta-analysis examining the relationship between RV dysfunction and cardiovascular outcomes and LV systolic function recovery in PPCM. This meta-analysis, including 5 studies and 472 participants, found that in patients with PPCM, RV dysfunction at the time of diagnosis is associated with a higher risk of major adverse clinical outcomes and a lower likelihood of LV systolic function recovery long term. After a median follow-up of 18.5 months, RV dysfunction in PPCM was associated with a 39% lower likelihood of LV systolic function recovery compared to those without RV dysfunction at diagnosis. With a median follow-up of 32.9 months, those with RV dysfunction were 4.2 times more likely to experience adverse clinical outcomes compared to women without RV dysfunction at the initial diagnosis of PPCM. These findings indicate that patients with PPCM who have biventricular failure are a higher-risk phenotype.

Studies in this meta-analysis indicated a reduced likelihood of LV systolic function recovery in PPCM patients with RV dysfunction, with ORs ranging from 0.32 to 0.46, and 3.21 to 4.77 for risk of adverse outcomes.^9,11,14,15 Most studies included multicenter cohort designs with patient populations in the United States, Canada, and Europe. Incidence of PPCM is higher in people from Haiti and the African subcontinent; however, there is a lack of published studies that include RV function from those groups. In a study from Senegal, RV dysfunction at diagnosis was 58% in the African population, but primary outcomes stratified by RV dysfunction were not reported.⁶ The Blauwet et al⁷ study contributed prominently to the LV systolic function recovery outcome (Figure 1) but minimally to the adverse event outcome (Figure 2). LV systolic function recovery was the main outcome for the Blauwet et al⁷ study. In contrast, very few participants in the Blauwet et al⁷ study developed the adverse outcomes (Figure 2), resulting in minimal contribution to the pooled adverse outcome data. Due to the low number of adverse events, the CI for the Blauwet et al⁷ study in Figure 2 is very wide. Additionally, the follow-up period for this study was shorter than in some of the other studies, with less time for the adverse outcomes to occur.

There are several possible mechanisms of RV dysfunction in PPCM. RV dysfunction may be due to intrinsic RV myocardial disease or, more commonly, secondary to LV myopathy, which can lead to an increased RV volume and pressure afterload. Also, RV dysfunction may be secondary to pulmonary hypertension.¹⁶ In addition, there may be a genetic predisposition to developing RV dysfunction in some patients. In a cohort of 229 women with PPCM, LV ejection fraction and pulmonary arterial systolic pressure were strong clinical factors that correlated with RV dysfunction, suggesting underlying pulmonary hypertension secondary to LV myopathy.¹⁵ A possible predisposition to RV dysfunction may occur due to an association with increased levels of sarcomeric protein titin and the dysfunction of ryanodine receptors in the ventricular walls, which has been observed in studies of LV dysfunction.17, 18, 19, 20 Titin is a key structural protein contributing to the elasticity of the myocardium, and its dysregulation leads to a stiffer cardiac musculature, compromising the right ventricle’s ability to contract and relax effectively.^17,18,21 Additionally, the ryanodine receptor dysfunction further disrupts calcium release, reducing the right ventricle’s contractile force.^19,22 Together, these factors may make the RV susceptible to failure under increased pressure or volume load conditions, particularly among pregnant patients.

Other mechanisms contributing to RV dysfunction in PPCM include RV ischemia and septal dysfunction. RV ischemia, often caused by microvascular dysfunction or impaired coronary perfusion, can lead to RV dilation, reduced contractility, and eventual failure. This elevates right atrial pressure, impairing LV filling and reducing cardiac output, thereby exacerbating biventricular dysfunction.²³ Furthermore, septal dysfunction, resulting from RV pressure overload or dyssynchronous contraction, can disrupt LV geometry and contractile efficiency, further compromising global LV systolic function.^23,24

Genetic studies including patients with PPCM have revealed some overlap with genetics of idiopathic dilated cardiomyopathy, although this remains to be elucidated.25, 26, 27 Specifically, the TTN gene, which encodes the sarcomere protein titin, has been identified as a major locus of interest. Truncating variants in TTN, particularly those located in the titin A-band, are the most prevalent genetic predisposition in both PPCM and idiopathic dilated cardiomyopathy. These genetic variations have been shown to alter diastolic stiffness and negatively impact systolic function.^18,21,25

Study Limitations

The current study has some limitations. All studies in the meta-analysis were retrospective designs rather than prospective data based on a predefined protocol. This retrospective nature introduces inherent selection biases, which consequently restrict the ability to control for confounding variables and limit the generalizability of our findings. Despite a low I² and an H² indicating minimal heterogeneity, differences in patient demographics and treatment protocols could impact the comparability of the data. While our funnel plot and Egger test indicated a low risk of bias, the possibility of publication bias remains, given the limited diversity and variability in baseline characteristics across the included studies. We conducted meta-regressions to account for sample size and age, indicating no significant associations on LV recovery or major adverse clinical outcomes. However, due to the unavailability of additional covariates across the studies, we were unable to compare additional variables. Another limitation is the differing methods of RV assessment and lack of follow-up for RV function data in all studies. Assessment of RV function may vary slightly depending on sonographer experience (tricuspid annular plane systolic excursion, FAC, and tissue Dopplers require precise Doppler alignment) as well as the ultrasound machine vendor (different vendors have variations in border detection software, leading to minor differences in RV strain and FAC values). Future studies should incorporate standardized assessment of RV global longitudinal strain to enhance reproducibility and comparability across different patient cohorts.

Our meta-analysis has several strengths. We conducted an extensive literature search across multiple databases, ensuring a wide capture of relevant studies. The application of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines further reinforces the reliability of the process. Additionally, the rigorous data extraction process, executed independently by 2 reviewers, minimizes the risk of bias and ensures the accuracy of findings. The meta-analysis encompasses studies from diverse geographic locations, thus broadening our patient population cohort. Additionally, all included studies uniformly considered LV assist device implantation, cardiac transplantation, and death as endpoints, and 1 study also accounted for hospitalization for heart failure as a separate outcome. The consistent definition of endpoints across studies improves comparability of adverse clinical outcome measures.

Conclusions

Our findings indicate that RV dysfunction at diagnosis is linked to a higher risk of major adverse clinical outcomes and a lower likelihood of LV systolic function recovery in patients with PPCM. While these results underscore the significance of RV dysfunction in PPCM, future research is needed to better understand its underlying mechanisms and the role of genetics, which could help identify high-risk patients and guide targeted therapies.

Perspectives.

COMPETENCY IN PATIENT CARE: Early identification of RV dysfunction in patients with peripartum cardiomyopathy will aid in risk stratification and inform prognosis, thereby allowing for more aggressive treatment strategies for higher-risk patients.

TRANSLATIONAL OUTLOOK: Further research is needed to fully understand the implications of RV dysfunction in PPCM, including the underlying mechanisms of dysfunction and the impact of genetics. Gaining insight into these factors can enhance patient management by guiding the development of targeted therapies and informing family planning.

Funding support and author disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.