Peripartum cardiomyopathy and triplet pregnancy

To the Editor,

We read with interest the article recently published by Günaydın et al. (1), entitled “Peripartum cardiomyopathy associated with triplet pregnancy,” in Anatolian J Cardiol 2014; 14: 661-2. However, we have some concerns about the article. First, although the authors claimed the current patient to be the first peripartum cardiomyopathy (PPCM) patient associated with triplet pregnancy in the literature, this may not be true. Rajab et al. (2) described a 26-year-old Bahraini primigravida, at 38 weeks of gestation for elective caesarean section because of pregnancy-induced hypertension and triplets. In this article, at the 39^th week, she had a cesarean section under general anesthesia but developed PPCM in the early postoperative period. Chapa et al. (3) reported follow-up data of 32 PPCM patients in 2005. They reported 4 women with multifetal gestations; 3 twins and 1 triplet. Golan et al. (4) reported a retrospective review and an analysis of 182 patients with PPCM. Twin or triplet pregnancies were reported in 15% of all patients in this study.

Our second concern is about the acute treatment of PPCM. The management of patients with PPCM is similar to that of other forms of non-ischemic dilated cardiomyopathy but must be individualized based on the patient’s clinical presentation (5). In addition to the standard therapeutic options for heart failure, specific targeted agents have been advocated for the treatment of PPCM. In recent years, it has been shown that addition of bromocriptine to standard heart failure therapy in women with PPCM results in significantly greater improvements in functional capacity and left ventricle function than with standard therapy alone. We have added bromocriptine in the acute phase of PPCM to standard heart failure therapy in our clinical practice since 2010.

Our last concern is about the duration of therapy. In the current study, the patient had normal left ventricle ejection fraction in the 6th month, but the authors did not report whether they continued the heart failure therapy or not after 6 months. Currently, there is no clear consensus on the appropriate duration of heart failure drug therapy. It is also unknown when to discontinue heart failure medications in recovered PPCM patients or whether there is any deterioration in left ventricular function after an initial recovery in these patients. Recently, we published the results of 42 prospectively followed PPCM patients (5). Four patients showed delayed deterioration (12, 24, 26, and 34 months after diagnosis) during the study period. The findings of late deterioration indicate the need for close follow-up with periodic determination of cardiac function in women in whom medications are discontinued after complete recovery. Due to the probability of either delayed recovery or deterioration of left ventricular function in PPCM, long-term follow-up may be needed not only in non-recovered patients but also in patients with complete recovery. After clinical and echocardiographic evidence of full recovery, it may be acceptable to gradually taper the drug doses over a period of 12 to 24 months; however, we suggest that ACE inhibitors and beta-blockers be continued for at least 2 years after complete recovery.