Abstract
It was carried out a study on peripartum cardiomyopathy (PPCM) in the cardiology and internal medicine department of the University Hospital Center of Brazzaville. This work takes place from May 1, 2019 to April 31, 2023. It had aimed at identifying the profile of peripartum cardiomyopathy in women disadvantaged in cardiovascular diseases. Fifty-two files were selected on the basis of predefined inclusion criteria. The frequency of myocardiopathy peripartum was estimated at 1.4% of admissions and 9.7% of women of childbearing age, or 13 cases per year. The average age of the patients was 30.78.02 (range: 16 to 44 years), the most frequently found risk factors were respectively high low level socio-economic (77%), multiparity (36%); pregnancy-induced hypertension (32%) and anemia (31%). clinical picture was stereotypical and included signs of heart failure. This one was global in thirty-nine (39) cases (75%), left in thirteen (13) cases (25%), cardiomegaly was noted in all cases with mean cardiothoracic ratio at 0.614 (range 0.52 to 0.83). Sinus tachycardia was observed in fifty-one 51 cases (98%). Left atrial dilatation was noted in twenty-three 23 cases (44.2%), left atrial dilatation was noted in thirteen (13) cases (25%). Diffuse disorders of the repolarization were noted in forty-three cases (83%). Echocardiography revealed: left cavitary dilatation in 100% of cases; thrombosis left ventricular intravenous was noted in two cases (4%).
Keywords
Cardiomyopathy, Peripartum, Brazzaville
1. Introduction
Peripartum cardiomyopathy (PPCM), or Meadows syndrome, is a condition rare in Europe
[1] | Ferrière M, Sacrez A, Bouhour JB et al – Peripartum cardiomyopathy current aspects. Multicenter study: eleven observations. Arch mal Cœur Vaiss 1990; 83: 1563–9. |
[1]
but quite common in underdeveloped countries and in particular Black Africa
[2] | Cenac A, Djibo A. Post-partum cardia failure in Sudanese – Sahelian Africa: Clinical prevalence in Western Niger. Am J. Trop. Med. Hyg. 1998; 58: 319-23. |
[3] | David NM, Parry EH, Peri-partum cardiac failure QJ Méd. 1978, 47: 431-61. |
[2, 3]
. The first observations of PPCM were reported by Ritchie at Oldenburg in 1849
[1] | Ferrière M, Sacrez A, Bouhour JB et al – Peripartum cardiomyopathy current aspects. Multicenter study: eleven observations. Arch mal Cœur Vaiss 1990; 83: 1563–9. |
[4] | Ritchie C. Clinical Contributions to the pathology, diagnostic and treatment of certain chronic diseases of the Heart Edinburgh M. and SJ 1849; 12: 333. |
[1, 4]
, and Virchow in 1870. The first precise description is due to Hull
[1] | Ferrière M, Sacrez A, Bouhour JB et al – Peripartum cardiomyopathy current aspects. Multicenter study: eleven observations. Arch mal Cœur Vaiss 1990; 83: 1563–9. |
[1]
.
PPCM is rare in the United States, Canada, and Europe. In the US, PPCM is diagnosed in 1 in every 1,000 to 1 in every 4,000 deliveries. The number of patients diagnosed with PPCM appears to be increasing over time. PPCM may be more common in other countries such as Haiti, Nigeria, and South Africa.
In 1937 (27 cases) and 1938 (80 cases). But the reference description is that made by Meadows
[5] | Meadows WR. Idiopathic myocardial failure in the last minister of pregnancy and the puerperium. Circulation, 1957, 15: 903-73. |
[5]
who defines the disease as “heart failure that occurs in the peripartum’’. Since then, the author's name has been given to the disease.
In 2010, the European Society of Cardiology described PPCM as an idiopathic cardiomyopathy with the following characteristics:
1. Development of heart failure toward the end of pregnancy or in the postpartum period.
2. Absence of another identifiable cause of the heart failure.
3. Left ventricular systolic dysfunction with a left ventricle (LV) ejection fraction nearly always less than 45 percent. The LV may or may not be dilated.
PPCM is of great scientific interest because of its prevalence in our regions and cause of its etiopathogenesis which remains unknown until now. Our study aims at the following objectives:
1) Determine the place of PPCM within cardiovascular diseases and heart failure.
2) Document the socio-economic characteristics of patients presenting this affection.
3) Document the risk factors for the disease.
4) Identify the epidemiological, ethiopathogenic and paraclinical characteristics therapeutic and evolving PPCMs.
2. Materials and Methods
2.1. Type, Setting and Period of Study
This study was carried out in the cardiology department B and internal medicine of the center Brazzaville University Hospital (CHUB). This was a retrospective study going from May 1, 2019 to April 31, 2023, a period 4 years old. We proceeded to read the entry registers longitudinally. We thus inventoried the admitted patients and selected the PPCM files.
During the reference period we listed 82 women with PPCM. Only 52 files were selected based on the criteria defined above.
A. Socio-economic categorization of patients
According to the standards used by the Congolese administration classifying patients into four socio-economic categories (CSE): we only retained the last two classes representing disadvantaged patients.
1) Categories I: salary with pay index varying between 830 and 2000 of the Congolese civil service: these are senior executives
2) Category II: employees with a salary index varying between: 530 and 820: these are middle managers
3) Category III: monthly income less than 530: these are workers and small employees
4) Category below IV: these are the destitute, often without social assistance.
B. Definition of concepts
Peripartum cardiomyopathy (PPCM) is a serious condition and is defined as a dilated cardiomyopathy which meets three necessary criteria: occurring during the period peripartum, no history of cardiovascular disease, no cause obvious. Symptoms appear between the last trimester of pregnancy and the fifth first months following childbirth
[1] | Ferrière M, Sacrez A, Bouhour JB et al – Peripartum cardiomyopathy current aspects. Multicenter study: eleven observations. Arch mal Cœur Vaiss 1990; 83: 1563–9. |
[6] | Oakley C, Child A, Lung B et al. Task Force on the Management of Cardiovascular Diseases During Pregnancy of the European Society of Cardiology: expert consensus document on management of cardiovascular diseases during pregnancy. Eur Heart J. 2003; 24 (8): 761-81. PubMed | Google Scholar. |
[7] | Abdelmajid Bouzerda et al. Peripartum cardiomyopathy: about an observation and review of the literature. Pan African Medical Journal. Volume 25, Article 21, 26 Sep 2016. |
[1, 6, 7]
. In addition, it meets the criteria characteristics of primary dilated cardiomyopathy defined by the Organization World Health
[1] | Ferrière M, Sacrez A, Bouhour JB et al – Peripartum cardiomyopathy current aspects. Multicenter study: eleven observations. Arch mal Cœur Vaiss 1990; 83: 1563–9. |
[1]
namely:
1) An unknown origin (idiopathic non-obstructive, non-ischemic).
2) A more or less significant dilation of one of the two ventricles.
3) Impairment of systolic function.
4) A progression towards heart failure.
5) A risk of death at all stages of the disease
The selected files met the following criteria:
1) Existence of signs of heart failure in the last trimester of pregnancy, during childbirth or during the five months following childbirth in disadvantaged patients.
2) Absence of known heart disease prior to pregnancy
3) Absence of a classic etiology that could lead to cardiac decompensation during the peripartum period
4) A medical file including: obstetric clinical data from the gynecology department of the Brazzaville University Hospital and that of cardiology and internal medicine. Biological examinations, chest x-ray, electrocardiogram and echocardiography/Doppler
2.3. Echocardiography Criteria
Dilation of at least the left ventricle (DTDLV> 32mm/m 2 of body surface area) associated with left ventricular systolic dysfunction, i.e. a lower left ventricular ejection fraction (LVEF) of 0.45 and/or or a shortening fraction < 30%.
2.4. Inclusion and Exclusion Criteria
It has included in these case series all patients with a low socio-economic level who presented the PPCM criteria. Those excluded from the study are patients with a high socio-economic level, patients who did not have an echocardiogram. Patients with a known cardiac condition prior to pregnancy.
This study looked for parameters likely to identify the profile of patients with PPCM, particularly in the following aspects: epidemiological (age, socio-economic, consultation time, obstetric history, course of pregnancy); Radiological, electrocardiographic, echo cardiographic, therapeutic and progressive clinics.
2.6. Statistical Analysis
The study used the mean of the standard deviation, the variance for the calculation of the mean age and measurements, and the chi-square test in the Epi-info 6.04 software for the comparisons. The significance threshold retained was 0.05.
3. Results
3.1. Epidemiological Aspects
Out of a total of 1856 patients admitted to the department during the study period for cardiovascular disease, 52 cases of PPCM occurring in disadvantaged women were listed, i.e. a frequency of 2.8% of cardiovascular diseases and a frequency of 9.7% of 534 women of childbearing age.
This frequency of PPCM in disadvantaged areas is estimated at 13 cases per year.
The patients were distributed by age groups as shown in
Table 2.
Table 1. Different age groups.
Age (year) | N | % |
11-20 | 8 | 15,3 |
21-30 | 12 | 23 |
31-40 | 29 | 55,7 |
≥ 40 | 3 | 6 |
TOTAL | 52 | 100% |
The average age of the patients was 30.7±8.2 (range 16 to 44 years).
The age group of 31 to 40 years was the most affected (n = 32 cases or 61.7%) with a peak in the age group of 31 to 40 years (n = 29 or 55.7%). 15-30 years versus 31-40 years: Chi2=5.54; P = 0.18.
3.1.3. Socio-Economic Status
Socio-economic category IV is dominant (n =40 or 77%); category III (n=12; 23%), All her patients were unemployed.
The parity of the patients was distributed as follows: multiparous (n=36; 69%); primiparous women (n=16; 31%). The average parity was 4 with extremes of 1 to 11. There is a statistically significant difference (p<10-5) between the group of disadvantaged primiparous women and that of multiparous women.
The following risk factors have been listed: Low socio-economic level (n=52; 100%); age>30 years (n=27; 52%); multiparity (n=36; 69%); hypoproteinemia (n=32; 61.5%); Pregnancy hypertension (n=17; 32.7%); anemia (n=16; 31%); twinning (n=4; 7.7%).
3.2.1. Time to Onset of PPCM
The patients were distributed according to the period of occurrence of clinical manifestations of PPCM such as: last trimester of pregnancy (n=17; 32.7%); 5 months after delivery (n=35; 67.3%).
The majority of patients showed clinical signs of PPCM in the postpartum period with a statistically significant difference (chi = 12.46; P = 0.0004).
Of the seventeen women who presented clinical manifestations of PPCM in the last trimester of pregnancy, the delivery method was cesarean section. We listed as fetal complications: acute fetal distress (n=7; 41.2%); neonatal death (n=4; 23.5%).
We divided the patients according to the period of occurrence of clinical manifestations of PPCM in the postpartum period such as: ≤3 months (n=28; 80%); >3 months (n=7; 20%). Chi=25.2; p = 10-6.
In total, 35 patients presented clinical manifestations in the 5 months following vaginal delivery, with a high peak in the trimester following delivery (n = 28 or 80%). The average interval between Delivery and first clinical signs was 600 ± 42 days (range: 2 to 180 days).
3.2.2. Functional Cardiac Signs
Table 2. Distribution according to functional signs of PPCM.
FS | N | % |
Class III and IV dyspnea | 52 | 100 |
Cough | 20 | 38,4 |
Palpitation | 7 | 13,5 |
Hémoptyssis | 2 | 3,8 |
Hépatalgia | 30 | 57,7 |
3.2.3. Main Examination Signs
Table 3. Distribution of patients according to main symptoms.
Symptôms | N | % |
Heart failure | 52 | 100 |
left ventricular failure | 39 | 75,0 |
global heart failure | 13 | 25,0 |
Auscultation: |
Tachycardia | 52 | 100,0 |
Galloping noise | 51 | 98,0 |
Mitral regurgitation murmur (MI) | 30 | 57,7 |
Tricuspid insufficiency (TI) murmur | 16 | 31,0 |
Compilation | | |
Acute pulmonary edema | 6 | 11,5 |
Pulmonary embolism | 3 | 6,0 |
3.2.4. Main Examination Signs
Table 4. Distribution of patients according to main symptoms.
RCT | N | % |
0,51-0,54 | 3 | 5,8 |
0,55-0,60 | 26 | 50 |
0,61-0,64 | 8 | 15,4 |
0,65-0,70 | 10 | 19,2 |
| 5 | 9,6 |
Total | 52 | 100 |
Cardiomegaly (CMG) was noted in all cases. The mean cardiothoracic ratio was 0.61 ± 4 with extremes of 0.52 to 0.83; 23 patients had an RCT greater than 0.60 or 44%
Table 5. Distribution of patients according to radiological signs.
Radiological signs | N | % |
Venocapillary stasis | 44 | 85 |
Images of broncho pneumonia | 8 | 15,4 |
Frank edema of the lungs | 6 | 11,5 |
Single or bilateral pleural effusion | 5 | 9,5 |
3.3.2. Electrocardiographic Data
Table 6. Distribution of patients according to electrical anomalies.
Electrical anomalies | N | % |
Sinus rhythm | 51 | 98 |
Atrial fibrillation | 1 | 2% |
Cavitary hypertrophy | 23 | 44,2 |
Left ventricular hypertrophy | 13 | 25 |
Left atrial hypertrophy | 3 | 5,8 |
Diffuse repolarization disorders | 43 | 82,7 |
Q wave of pseudo necrosis | 1 | 2 |
Arhythmia | 3 | 5,8 |
Ventriculair | | |
Ventricular extrasystoles | 1 | 2 |
Complete left bundle branch block | 2 | 3,8 |
Supraventricular | | |
Supraventricular extrasystoles | 1 | 2 |
3.3.3. Doppler Echocardiographic Data
LV dilation (n=52; 100%); RV dilatation (n=40; 77%). LV ejection fraction ≤45 (n=43; 82.7%), LV shortening fraction < (n=39; 75%) IVC evaluated in 29 patients had a mean of 20±5.5 mm (range: 13 to 28 mm).
Pericardial effusion of minimal abundance was noted in six cases, i.e. 135 cases of mitral regurgitation by annular dilatation. 20 cases of Tricuspid regurgitation by annular dilatation. The average systolic pulmonary arterial pressure was evaluated in 24 patients and was 40.5 ± 20 (extreme): 28 to 60 mm Hg). Left intraventricular thrombus was observed in 2 cases or 4%.
Table 7. Distribution of patients according to the average of the anatomical measurements obtained.
Measurements | Average | Standard deviations | Extremes |
LV (mm) diastole | 60 | | 50-69,6 |
systole | 45,3 | | 31- 56,2 |
LA | 40 | | 31- 50, 1 |
LA/OA | 1,4 | | 1,3 -1,9 |
RV (mm) diastole | 30,5 | | 17,2-46 |
The blood count revealed normocytic normochromic anemia in twelve patients (31%) (tx Hb < 11g/dl), four patients had hypochromic microcytic anemia (8%), i.e. a total of 39% of patients who presented anemia in peripartum among these patients. In four (23.5%), delivery hemorrhage was noted. The average hemoglobin level was 7.5±2.2 (range: 3.3 to 10.7 g/dl). An inflammatory syndrome was noted in almost all patients with a sedimentation rate greater than 45 mm at the first hour and an average of 70 ± 13.5 (range: 45 and 102). The BNPs were not carried out due to lack of financial means on the part of the patients.
Renal failure (IR) with serum creatinine of 37.1g/l and creatinine clearance of 18.4ml/l in a 22-year-old primiparous woman with pregnancy-related hypertension (high BP 170/100 mm Hg). HIV serology was unfortunately only carried out in 21 patients. She was positive in 1 case or 2%. Hypoproteinemia < 60g/mg was only observed in thirty-two (32) patients, or 61.5%. The rest of the biological tests T4, TSH, proteinuria, viral serology could not be obtained.
The treatment of PPCM is above all medical, different therapeutic protocols had been used associated with the low-sodium diet depending on the economic situation:
Protocol 1: Diuretics, ACE inhibitor/ARA2 and anticoagulants, Beta blockers
Protocol 2: Nitrogen derivatives, diuretics and beta-blockers
Protocol 3: Digitalis, Diuretic, ACE inhibitor, Anti aldosterone and Anticoagulants.
Table 8. Distribution of diseases according to different protocols used.
Protocols | N | % |
Protocol N°1 | 5 | 9,6 |
Protocol N°2 | 17 | 32,7 |
Protocol N°3 | 30 | 57,7 |
Total | 52 | 100,0 |
Protocol No. 2 was indicated in women presenting with PPCM in the last trimester of pregnancy. No. 3 in serious patients.
3.6. Evolutionary Aspects
The evolving aspects were considered from a clinical and radiological perspective. Indeed, echocardiographic checks of patients could not be obtained systematically.
Hospital development
The average length of hospitalization was 19 ± 12 days (range 5 to 102 days). Under well-monitored treatment, the evolution was favorable from the outset in 27 patients, or 52%.
Hospital morbidity: During hospitalization, we noted as complications: Repeated pulmonary embolisms in 3 patients (6%), Arterial embolism (acute ischemia of both lower limbs in one patient, i.e. 2%), Persistence atrial fibrillation in one patient, i.e. 2%And the delivery hemorrhage in 4 patients or 7.8. Ultimately, resolution of the initial heart failure affected 86.5% of patients, the cardio-thoracic ratio went from 0.61±4 to 0.50±1 (extreme 0.41 to 0.70).
Mortality: Two cases were noted, i.e. 3.8% deaths, one from pulmonary embolism, and the other from cardiogenic shock linked to arterial embolism.
The progressive modalities obtained for all of our patients: initial resolution (n=45; 86.5%); recurrences (n=5; 9.5%).
Favorable evolution according to the time of occurrence of PPCM: last trimester of pregnancy (n=15; 33.3%), after delivery (n=30; 66.5%). Chi = 10.0; P = 0.0015.
Medium-term evolution:
Hospital follow-up in outpatient cardiology consultation allowed us (on average 18 months):
14 women were lost to follow-up (27%) • 31 women remained stable (60%) • 4 cases of recurrent heart failure (9.6%) • 1 case of recurrence during pregnancy (2%).
4. Discussion
4.1. Epidemiological Aspects
This series collected over 4 years shows a frequency of PPCM of 2.8% of total entries, it remained the same in our department (2.7%) more than 10 years ago
[8] | Solange F. Mongo Ngamami, Bertrand F. Ellenga Mbolla, Siama Nzaka-Sikou et al. Peripartum cardiomyopathy: epidemiological, clinical and prognostic aspects in the cardiology and internal medicine department of the CHU de Brazzaville (Congo). CAMES SANTE Vol. 2, N° 1, Juillet 2014; 69-73. |
[8]
. However, it is comparable to that of other African authors
[9] | Kane Ad, Mbaye M, Ndiaye MB, et al. Evolution and thromboembolic complications of peripartum idiopathic cardiomyopathy at Dakar University Hospital: a prospective study of 33 cases. J Gynecol Obstet Biol Reprod 2010; 39: 484-9. |
[9]
.
This frequency is 9.7% compared to women of childbearing age. This rate is higher than that of Nkoua
[10] | Nkoua JL, Kimbaly-Kaky G, Onkani AH, Kandosi S, Bouramoue C. Postpartum cardiomyopathy: about 24 cases. Cardiol Trop 1991; 17: 105–9. |
[10]
, Congo-Brazzaville (3.2%). This difference in frequency seems to be due to the fact that during the reference period most of the births admitted to the cardiology department had benefited from an echocardiogram with the diagnosis of PPCM. In addition, this frequency is 13 cases per year. A. NIAKARA
[11] | A. NIAKARA, BELENWIRE, et coll. Postpartum cardiomyopathy in black African women: epidemiological, clinical and evolutionary aspects of 32 cases. Cardiologie tropicale 2000. 26: 69-73. |
[11]
and NKOUA
[10] | Nkoua JL, Kimbaly-Kaky G, Onkani AH, Kandosi S, Bouramoue C. Postpartum cardiomyopathy: about 24 cases. Cardiol Trop 1991; 17: 105–9. |
[10]
find respectively (6.4 and 8 cases) per year.
Age and parity
Peripartum cardiomyopathy mainly affects women after the age of 30
[12] | Kolte, D. et al. Temporal trends in incidence and outcomes of peripartum cardiomyopathy in the United States: a nationwide population-based study. J. Am. Heart Assoc. 3, e001056 (2014). |
[12]
. In our series the average age was 30.7±8.2 years. This figure is consistent with the results of the literature
[12] | Kolte, D. et al. Temporal trends in incidence and outcomes of peripartum cardiomyopathy in the United States: a nationwide population-based study. J. Am. Heart Assoc. 3, e001056 (2014). |
[13] | Duran N, Günes H, Duran I, Biteker M, Özkan M. Predictors of prognosis in patients with peripartum cardiomyopathy. Int J Gynecol Obstet 2008; 101: 137–40. |
[14] | Machihude Pio, Yaovi Afassinou, Soodougoua Baragou et al. Particularities of peripartum cardiomyopathy in Africa: the case of Togo on a prospective study of 41 cases at the Sylvanus Olympio University Hospital in Lomé. Pan Afr Med J. 2014; 17: 245. |
[12-14]
.
Elderly multiparous women represent 69% in our series with an average parity equal to 4. It is sensitive to those of A. NIAKARA
[11] | A. NIAKARA, BELENWIRE, et coll. Postpartum cardiomyopathy in black African women: epidemiological, clinical and evolutionary aspects of 32 cases. Cardiologie tropicale 2000. 26: 69-73. |
[11]
who found 3.88 and Machihude Pio et al who found 82.93% of multiparous women with a average parity of 3.07
[14] | Machihude Pio, Yaovi Afassinou, Soodougoua Baragou et al. Particularities of peripartum cardiomyopathy in Africa: the case of Togo on a prospective study of 41 cases at the Sylvanus Olympio University Hospital in Lomé. Pan Afr Med J. 2014; 17: 245. |
[14]
.
In our series, all patients were black. Black race constitutes a risk factor recognized in the literature
[15] | Mielniczuk, L. M. et al. Frequency of peripartum cardiomyopathy. Am. J. Cardiol. 97, 1765–1768 (2006). |
[15]
.
Socio-economic status
In the literature, the vast majority of cases of PPCM are observed in disadvantaged areas
[16] | Modi KA, Illum S, Jariatul K, Caldito G, Reddy PC. Poor outcome of indigent patients with peripartum cardiomyopathy in the United States. Am J Obstet Gynecol 2009; 201: 171. e1-5. |
[17] | Bahloul M, Ahmed MN, Laaroussi L et al. Myocardiopathie du péripartum: incidence, physiopathologie, manifestations cliniques prise en charge et pronostic. Ann Fr Anesth Reanim 2009; 28: 44–60. |
[29] | Katibi I. Peripartum cardiomyopathy in Nigeria. Hesp Med. 2003; 64 (4): 249. [PubMed] [Google Scholar]. |
[16, 17, 29]
. This observation is confirmed by our study with 100% cases.
Low socio-economic level is strongly implicated in the occurrence of PPCM. Indeed, social precariousness is responsible for malnutrition and therefore hypoproteinemia, vitamin deficiencies, and iron and trace element deficiency which can in turn lead to hemodynamic disorders responsible for PPCM
[1] | Ferrière M, Sacrez A, Bouhour JB et al – Peripartum cardiomyopathy current aspects. Multicenter study: eleven observations. Arch mal Cœur Vaiss 1990; 83: 1563–9. |
[1]
. However, it is also described to a lesser extent in patients with a high social level.
Pre-eclampsia
Pregnancy-related hypertension represents 32% of cases in our study, similar figures were found in the literature. Indeed, high blood pressure and pre-eclampsia are powerful risk factors. A meta-analysis published in 2013 brought together 22 studies including 979 patients diagnosed with PPCM. The prevalence of preeclampsia was 22%, more than 4 times the 5% of the general population
[18] | Bello, N., Rendon, I. S. H. & Arany, Z. The relationship between pre-eclampsia and peripartum cardiomyopathy: a systematic review and meta-analysis. J. Am. Coll. Cardiol. 62, 1715–1723 (2013). |
[18]
.
These results prove that there is a close link between pregnancy-related hypertension and PPCM. Hypertension represents a risk factor that is all the more important and must be taken into consideration, especially as its prevalence is increasing in Africa. A very salty diet as required by African custom is likely to create the conditions for a hypertensive surge in the postpartum period
[7] | Abdelmajid Bouzerda et al. Peripartum cardiomyopathy: about an observation and review of the literature. Pan African Medical Journal. Volume 25, Article 21, 26 Sep 2016. |
[7]
.
Anemia
It represents 31% of cases in our series with an average hemoglobin level of 7.5±2.2 A. NIAKARA
[11] | A. NIAKARA, BELENWIRE, et coll. Postpartum cardiomyopathy in black African women: epidemiological, clinical and evolutionary aspects of 32 cases. Cardiologie tropicale 2000. 26: 69-73. |
[11]
found a high level of 10.7±1.7g/dI). Our results show that anemia is sometimes the cause of cardiac decompensation in the peripartum
[20] | CENAC A., GAULTIER Y., SOUMANA I., et coll. Postpartum cardiomyopathy: clinical and echographic evaluation of response to treatment. Thirty cases from the Sudano-Sahelian region – Presse Méd. 1988; 17: 940–944. |
[20]
: hence the need, according to certain authors, to provide iron supplementation to all pregnant women, given that the capital ferric is revised downward during this period.
Twinship
Twinning is poorly represented in our series (7.7%). Some authors admit that it is also one of the risk factors for this condition.
PPCM is more common in multiple pregnancies. In the previously cited meta-analysis, the prevalence of multiple pregnancies was 9%, compared to 3% in the general population
[18] | Bello, N., Rendon, I. S. H. & Arany, Z. The relationship between pre-eclampsia and peripartum cardiomyopathy: a systematic review and meta-analysis. J. Am. Coll. Cardiol. 62, 1715–1723 (2013). |
[18]
.
Infections
HIV is not widely represented in our series. In the literature it is commonly accepted that there is a correlation between PPCM and HIV infection
[19] | Arnould N, Diemunsch P, Raiga J, Brettes JP Gynecol obstét Fertil 2002; 30: 59-63. |
[19]
. In these cases, we can discuss a concomitant cardiac attack with AIDS.
Taking into account the various risk factors mentioned above, it is clear that in the literature it is commonly accepted that PPCM is a primary dilated cardiomyopathy of unknown cause affecting white women in small proportions and black African women in large proportions. The latter most often have a precarious socio-economic level and therefore difficulties in accessing good living conditions and medical care could largely make this difference. We can also say that its etiology in our region is multifactorial and that only hypertension, anemia, malnutrition and infections seem to constitute serious areas of etiological research.
In these mice, cardiac cathepsin D (CD) expression and activity is enhanced and associated with the generation of a cleaved antiangiogenic and proapoptotic 16 kDa form of the nursing hormone prolactin
[21] | Hilfi ker-Kleiner, D. et al. A cathepsin D-cleaved 16 kDa form of prolactin mediates postpartum cardiomyopathy. Cell 128, 589–600 (2007). |
[21]
.
However, recent data also support the probable hormonal hypothesis
[18] | Bello, N., Rendon, I. S. H. & Arany, Z. The relationship between pre-eclampsia and peripartum cardiomyopathy: a systematic review and meta-analysis. J. Am. Coll. Cardiol. 62, 1715–1723 (2013). |
[18]
: The first hypothesis is that of a vascular disease, linked to the strong hormonal influence at the end of pregnancy. The second hypothesis argues in favor of a genetic component after several observations
[22] | Horne, B. D. et al. Genome-wide signifi cance and replication of the chromosome 12p11.22 locus near the PTHLH gene for peripartum cardiomyopathy. Circ. Cardiovasc. Genet. 4, 359–366 (2011). |
[23] | Haghikia, A. et al. Phenotyping and outcome on contemporary management in a German cohort of patients with peripartum cardiomyopathy. Basic Res. Cardiol. 108, 366 (2013). |
[22, 23]
. Other inflammatory, viral and autoimmune hypotheses have also been mentioned in the literature
[25] | Sliwa, K. et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur. J. Heart Fail. 12, 767–778 (2010). |
[25]
.
Time to onset of PPCM
The predominant period for the occurrence of clinical manifestations of PPCM is postpartum
[26] | ZABSONRE P, BAMOUNI J, FR FALL, DAOB, DYEMKOUMA-Fx. Epidemiology of peripartum heart failure: 116 cases in BOBO - DIOULASSO – Médecine d’Afrique Noire 2000, 47(4). |
[26]
. In the majority of cases (78%), symptoms appear during the first 4 months after delivery. In only 9% of cases, symptoms appear in the last month of pregnancy. 13% of women become symptomatic before the ninth month of pregnancy or beyond the first 4 months postpartum
[27] | Lampert, M. B. et Lang, R. M. Peripartum cardiomyopathy. Am. Heart J. 130, 860–870 (1995). |
[27]
.
In our series, 67% of cases of PPCM occurred postpartum. However, the first three months following childbirth represent the predilection period for the onset of the disease; the literature is almost unanimous on this subject
[14] | Machihude Pio, Yaovi Afassinou, Soodougoua Baragou et al. Particularities of peripartum cardiomyopathy in Africa: the case of Togo on a prospective study of 41 cases at the Sylvanus Olympio University Hospital in Lomé. Pan Afr Med J. 2014; 17: 245. |
[28] | CENAC A., GAULTIER Y., SOURNANA I., HA ROUNAY, DEVELOUX M. Postpartum cardiomyopathy in the Sudano-Saharan region: a clinical and epistemological study of 66 cases. Arch. mal. Cœur vaiss. 1989; 82: 553-558. |
[14, 28]
.
Cardiac functional and physical signs
In our series, congestive heart failure dominates the clinical picture with 75% of cases. The same findings are described in the literature
[14] | Machihude Pio, Yaovi Afassinou, Soodougoua Baragou et al. Particularities of peripartum cardiomyopathy in Africa: the case of Togo on a prospective study of 41 cases at the Sylvanus Olympio University Hospital in Lomé. Pan Afr Med J. 2014; 17: 245. |
[29] | Katibi I. Peripartum cardiomyopathy in Nigeria. Hesp Med. 2003; 64 (4): 249. [PubMed] [Google Scholar]. |
[30] | MBOULLET KOTTO R., BOUELET B. A. Postpartum cardiomyopathy in Douala: 12 observations card. Trop. 1999: 25: 98. |
[31] | Ntusi N, Mayosi BM. Étiologie et facteurs de risque de cardiomyopathie péripartum: une revue systématique. Int J Cardiol. 2009; 131(2): 168-79. [PubMed] [Google Scholar]. |
[14, 29-31]
. It is important to point out here the preponderant place of late consultations linked to financial difficulties.
Inherent to this socio-economic category of patients. In addition, a certain number of symptoms, such as sloping edema of the lower limbs, exertional dyspnea, and orthopnea may be wrongly attributed to pregnancy.
4.2.2. Paraclinical Aspects
Radiological data
In our series, thoracic cardiomegaly (CMG) was noted in 100% of cases. The average cardiothoracic ratio was 0.61±4. Our results are consistent with literature data
[32] | Mandji LJM, Mayi S, Sima A, et al. Postpartum cardiomyopathy: About five cases in Gabon. Clin Mother Child Health. 2009; 6: 1037–41. |
[33] | Moioli M, Valenzano Menada M, Bentivoglio G, Ferrero S. Peripartum cardiomyopathy. Arch Gynecol Obstet. 2010; 281(2): 183-8. [PubMed] [Google Scholar]. |
[32, 33]
.
Electrical anomalies
They vary in the literature. Our series did not record any serious arrhythmias. However, in certain situations and dramatically, it is sometimes ventricular arrhythmias or sudden death that can lead to the diagnosis
[34] | Diao, M. et al. [Electrocardiographic recording of long duration (Holter) of 24 hours during idiopathic cardiomyopathy of the peripartum]. Arch. Mal. Coeur Vaiss. 97, 25–30 (2004). |
[34]
. Also an American study which included 9841 adult women for a PPCM: among them, 18.7% presented ventricular arrhythmias, responsible for greater morbidity and mortality, longer lengths of stay, higher costs of hospitalization with more additional examinations carried out, compared to women who did not present arrhythmias
[38] | Mallikethi-Reddy, S. et al. Burden of arrhythmias in peripartum cardiomyopathy: Analysis of 9841 hospitalizations. Int. J. Cardiol. 235, 114–117 (2017). |
[38]
.
Echocardiography
It showed dilatation of the LV and an alteration of ventricular function in all cases. This heart failure observed corroborates the data in the literature
[10] | Nkoua JL, Kimbaly-Kaky G, Onkani AH, Kandosi S, Bouramoue C. Postpartum cardiomyopathy: about 24 cases. Cardiol Trop 1991; 17: 105–9. |
[24] | Ware, J. S., Seidman, J. G. et Arany, Z. Shared Genetic Predisposition in Peripartum and Dilated Cardiomyopathies. N. Engl. J. Med. 374, 2601–2602 (2016). |
[10, 24]
. Indeed, echocardiography is a tool of choice, making it possible to confirm left ventricular systolic dysfunction, to assess the degree of left ventricular dilatation, to quantify possible valvulopathies as well as possible associated right ventricular dysfunction and to search for a left intraventricular thrombus. It is of prognostic interest in cases of significant left ventricular dilatation (end-diastolic diameter greater than 60 mm) or severe systolic dysfunction of the left ventricle (ejection fraction less than 30%)
[35] | Chapa, J. B. et al. Prognostic value of echocardiography in peripartum cardiomyopathy. Obstet. Gynecol. 105, 1303–1308 (2005). |
[35]
.
Left intracavitary thrombosis was found in our series in 4% of cases. It should be noted in passing that in the literature PPCM is considered an emboligenic disease
[35] | Chapa, J. B. et al. Prognostic value of echocardiography in peripartum cardiomyopathy. Obstet. Gynecol. 105, 1303–1308 (2005). |
[36] | Duran, N., Günes, H., Duran, I., Biteker, M. et Ozkan, M. Predictors of prognosis in patients with peripartum cardiomyopathy. Int. J. Gynaecol. Obstet. Off. Organ Int. Fed. Gynaecol. Obstet. 101, 137–140 (2008). |
[35, 36]
. Indeed, the combination of a hypercoagulable pregnancy state, intracardiac blood stagnation, endothelial dysfunction and possible immobilization would favor this thrombogenic state
[39] | Elkayam, U. Clinical characteristics of peripartum cardiomyopathy in the United States: diagnosis, prognosis, and management. J. Am. Coll. Cardiol. 58, 659–670 (2011). |
[39]
. Curative anticoagulation therefore seems reasonable in cases of severe systolic dysfunction of the left ventricle (ejection fraction less than 35%) during the end of pregnancy and the first two months postpartum. Anti-Vitamins K are contraindicated during pregnancy
[25] | Sliwa, K. et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur. J. Heart Fail. 12, 767–778 (2010). |
[25]
.
The average pulmonary arterial systolic pressure (PAPS) was 40.5±20, which indicates pulmonary arterial hypertension observed in PPCM
[26] | ZABSONRE P, BAMOUNI J, FR FALL, DAOB, DYEMKOUMA-Fx. Epidemiology of peripartum heart failure: 116 cases in BOBO - DIOULASSO – Médecine d’Afrique Noire 2000, 47(4). |
[26]
.
The treatment of PPCM follows the conventional treatment of heart failure with low systolic ejection fraction; it is necessary to point out the role of prolonged rest from a low-salt diet which is one of the essential elements of the treatment.
The PPCM management should focus on three elements: reduction in pre-load, reduction in afterload, and increase in inotropy
[40] | Egan, D. J., Bisanzo, M. C. et Hutson, H. R. Emergency department evaluation and management of peripartum cardiomyopathy. J. Emerg. Med. 36, 141–147 (2009). |
[40]
.
In the postpartum period, ACE inhibitors/ARA2 and mineralocorticoid receptor antagonists are also prescribed in European and other countries. On the other hand, beta-blockers and ivabradine were more often prescribed in European countries and diuretics, bromocriptine and digoxin were less so
[37] | Sliwa, K. et al. Clinical characteristics of patients from the worldwide registry on peripartum cardiomyopathy (PPCM): EURObservational Research Programme in conjunction with the Heart Failure Association of the European Society of Cardiology Study Group on PPCM. Eur. J. Heart Fail. 19, 1131–1141 (2017). |
[37]
.
Beta-blockers can be used during pregnancy; selective beta-blockers of beta-1 adrenergic receptors are then recommended, in order to avoid the risk of uterine stimulation.
Diuretics and nitrates can be used during pregnancy, while paying attention to the risk of uterine hypoperfusion in the event of arterial hypotension
[41] | Ghuman, N., Rheiner, J., Tendler, B. E. et White, W. B. Hypertension in the postpartum woman: clinical update for the hypertension specialist. J. Clin. Hypertens. Greenwich Conn 11, 726–733 (2009). |
[41]
. Furosemide and hydrochlorothiazide are commonly used. Anti-aldosterones should be avoided during pregnancy, due to their fetal anti-androgenic effect. ACE inhibitors and ARBs2 are contraindicated during pregnancy, and only certain ACE inhibitors are authorized during breastfeeding
[42] | Rasmusson, K. et al. Peripartum cardiomyopathy: post-transplant outcomes from the United Network for Organ Sharing Database. J. Heart Lung Transplant. Off. Publ. Int. Soc. Heart Transplant. 31, 180–186 (2012). |
[42]
. Effective contraception is essential in these young women following a first episode of PPCM. In cases of persistent dysfunction, further pregnancy should be discouraged, and contraindicated due to the high risk of death.
In the event of cardiogenic shock, inotropes should be considered as a first resort.
In the absence of recovery of ventricular function, cardiac resynchronization may be offered, left ventricular assistance and, as a last resort, heart transplantation
[43] | McNamara, D. M. et al. Clinical Outcomes for Peripartum Cardiomyopathy in North America: Results of the IPAC Study (Investigations of Pregnancy-Associated Cardiomyopathy). J. Am. Coll. Cardiol. 66, 905–914 (2015). |
[43]
.
Prognostic and evolutionary modalities
PPCM is generally sensitive to conventional treatment of congestive heart failure, clinical signs disappear within a few weeks, cardiomegaly within a few months or even a year
[7] | Abdelmajid Bouzerda et al. Peripartum cardiomyopathy: about an observation and review of the literature. Pan African Medical Journal. Volume 25, Article 21, 26 Sep 2016. |
[43] | McNamara, D. M. et al. Clinical Outcomes for Peripartum Cardiomyopathy in North America: Results of the IPAC Study (Investigations of Pregnancy-Associated Cardiomyopathy). J. Am. Coll. Cardiol. 66, 905–914 (2015). |
[7, 43]
.
The particularity of PPCM compared to secondary CMD is its possibility of definitive cure
[43] | McNamara, D. M. et al. Clinical Outcomes for Peripartum Cardiomyopathy in North America: Results of the IPAC Study (Investigations of Pregnancy-Associated Cardiomyopathy). J. Am. Coll. Cardiol. 66, 905–914 (2015). |
[43]
. It was noted in 31% of our patients.
In our series, incomplete remission represents 9.6%; other authors find higher figures. A. NIAKA
[11] | A. NIAKARA, BELENWIRE, et coll. Postpartum cardiomyopathy in black African women: epidemiological, clinical and evolutionary aspects of 32 cases. Cardiologie tropicale 2000. 26: 69-73. |
[11]
, finds 26.9%. This difference in rates is explained by the fact that 27% of our patients were lost to follow-up.
We recorded 2 cases of death (3; 8%), one linked to pulmonary embolism and the other to arterial embolism (acute ischemia of two lower limbs) and this during the hospital period. Mortality at 1 year was 4% in a large prospective North American study which followed 100 women treated for PPCM for 12 months
[43] | McNamara, D. M. et al. Clinical Outcomes for Peripartum Cardiomyopathy in North America: Results of the IPAC Study (Investigations of Pregnancy-Associated Cardiomyopathy). J. Am. Coll. Cardiol. 66, 905–914 (2015). |
[43]
.
This fatal outcome observed in our series precipitated by thromboembolic accidents confirms the data in the literature
[19] | Arnould N, Diemunsch P, Raiga J, Brettes JP Gynecol obstét Fertil 2002; 30: 59-63. |
[43] | McNamara, D. M. et al. Clinical Outcomes for Peripartum Cardiomyopathy in North America: Results of the IPAC Study (Investigations of Pregnancy-Associated Cardiomyopathy). J. Am. Coll. Cardiol. 66, 905–914 (2015). |
[19, 43]
.
In our series we recorded one case of recurrence during pregnancy. This seems to be explained by the fact that the rate of patients lost to follow-up is high, around 27%. And also by the fact that most of our patients in complete remission at 6 months had a stable recovery over time. These same observations were made by A. NIAKARA
[19] | Arnould N, Diemunsch P, Raiga J, Brettes JP Gynecol obstét Fertil 2002; 30: 59-63. |
[19]
in his series of 32 cases of PPCM, no recurrence of heart failure was noted.
In the event of pregnancy, strict clinical, echocardiographic and biological (BNP) monitoring is recommended. Furthermore, an in-depth discussion around the different possible contraceptive methods is essential.
Certain parameters are considered poor prognosis. These are African origin, age greater than 30 years, a time to onset of symptoms greater than 3 months, persistence of clinical signs 6 months after the onset of the disease, an ICT greater than 0.6 and the characteristics of the left ventricle: slight dilation (DTDLV < 55-60 mm), ejection fraction < 30%, shortening fraction less than 20% at the time of diagnosis
[43] | McNamara, D. M. et al. Clinical Outcomes for Peripartum Cardiomyopathy in North America: Results of the IPAC Study (Investigations of Pregnancy-Associated Cardiomyopathy). J. Am. Coll. Cardiol. 66, 905–914 (2015). |
[43]
.
5. Conclusion
This study stands out some evolutionary etiopathogenic particularities of Peripartum Cardiomyopathy. it is clear that in the literature it is commonly accepted that PPCM is a primary dilated cardiomyopathy of unknown cause affecting white women in small proportions and black African women in large proportions. The majority of patients showed clinical signs of PPCM in the postpartum period with a statistically significant difference.
Its etiologies in our region is multifactorial and that only hypertension, anemia, malnutrition and infections seem to constitute serious areas of etiological research.
Abbreviations
PPCM: Peripartum Cardiomyopathy
DTDLV: Left Ventricular Telediastolic Diameter
LVEF: Left Ventricular Ejection Farction
CMD: Cardiomyopathy Dilated
CMG: Cardiomegaly
AIDS: Acquiered Immunodeficiency Syndrome
HIV: Human Immunodeficiency Virus
IVC: Inferior Vein Cave
Conflicts of Interest
The authors declare no conflicts of interest.
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Diao, M. et al. [Electrocardiographic recording of long duration (Holter) of 24 hours during idiopathic cardiomyopathy of the peripartum]. Arch. Mal. Coeur Vaiss. 97, 25–30 (2004).
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|
Cite This Article
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APA Style
Ngamani, S. F. M., Letomo, K. M. N., Landa, C. M. K., Kaky, E. G. K., Bakekolo, R. P., et al. (2024). Evolutionary Etiopathogenic Particularities of Peripartum Cardiomyopathy in a Disadvantaged Environment in Brazzaville
. Cardiology and Cardiovascular Research, 8(2), 56-64. https://doi.org/10.11648/j.ccr.20240802.12
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Ngamani, S. F. M.; Letomo, K. M. N.; Landa, C. M. K.; Kaky, E. G. K.; Bakekolo, R. P., et al. Evolutionary Etiopathogenic Particularities of Peripartum Cardiomyopathy in a Disadvantaged Environment in Brazzaville
. Cardiol. Cardiovasc. Res. 2024, 8(2), 56-64. doi: 10.11648/j.ccr.20240802.12
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Ngamani SFM, Letomo KMN, Landa CMK, Kaky EGK, Bakekolo RP, et al. Evolutionary Etiopathogenic Particularities of Peripartum Cardiomyopathy in a Disadvantaged Environment in Brazzaville
. Cardiol Cardiovasc Res. 2024;8(2):56-64. doi: 10.11648/j.ccr.20240802.12
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@article{10.11648/j.ccr.20240802.12,
author = {Solange Flore Mongo Ngamani and Kivie Mou-moue Ngolo Letomo and Christian Michel Kouala Landa and Eric Gibrel Kimbally Kaky and Rog Paterne Bakekolo and Synthiche Okoko and Gankama Thibault Naibe and Jospin Karel Makani Bassoukouahou and Fikahem Ellenga Mbolla},
title = {Evolutionary Etiopathogenic Particularities of Peripartum Cardiomyopathy in a Disadvantaged Environment in Brazzaville
},
journal = {Cardiology and Cardiovascular Research},
volume = {8},
number = {2},
pages = {56-64},
doi = {10.11648/j.ccr.20240802.12},
url = {https://doi.org/10.11648/j.ccr.20240802.12},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ccr.20240802.12},
abstract = {It was carried out a study on peripartum cardiomyopathy (PPCM) in the cardiology and internal medicine department of the University Hospital Center of Brazzaville. This work takes place from May 1, 2019 to April 31, 2023. It had aimed at identifying the profile of peripartum cardiomyopathy in women disadvantaged in cardiovascular diseases. Fifty-two files were selected on the basis of predefined inclusion criteria. The frequency of myocardiopathy peripartum was estimated at 1.4% of admissions and 9.7% of women of childbearing age, or 13 cases per year. The average age of the patients was 30.78.02 (range: 16 to 44 years), the most frequently found risk factors were respectively high low level socio-economic (77%), multiparity (36%); pregnancy-induced hypertension (32%) and anemia (31%). clinical picture was stereotypical and included signs of heart failure. This one was global in thirty-nine (39) cases (75%), left in thirteen (13) cases (25%), cardiomegaly was noted in all cases with mean cardiothoracic ratio at 0.614 (range 0.52 to 0.83). Sinus tachycardia was observed in fifty-one 51 cases (98%). Left atrial dilatation was noted in twenty-three 23 cases (44.2%), left atrial dilatation was noted in thirteen (13) cases (25%). Diffuse disorders of the repolarization were noted in forty-three cases (83%). Echocardiography revealed: left cavitary dilatation in 100% of cases; thrombosis left ventricular intravenous was noted in two cases (4%).
},
year = {2024}
}
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TY - JOUR
T1 - Evolutionary Etiopathogenic Particularities of Peripartum Cardiomyopathy in a Disadvantaged Environment in Brazzaville
AU - Solange Flore Mongo Ngamani
AU - Kivie Mou-moue Ngolo Letomo
AU - Christian Michel Kouala Landa
AU - Eric Gibrel Kimbally Kaky
AU - Rog Paterne Bakekolo
AU - Synthiche Okoko
AU - Gankama Thibault Naibe
AU - Jospin Karel Makani Bassoukouahou
AU - Fikahem Ellenga Mbolla
Y1 - 2024/04/11
PY - 2024
N1 - https://doi.org/10.11648/j.ccr.20240802.12
DO - 10.11648/j.ccr.20240802.12
T2 - Cardiology and Cardiovascular Research
JF - Cardiology and Cardiovascular Research
JO - Cardiology and Cardiovascular Research
SP - 56
EP - 64
PB - Science Publishing Group
SN - 2578-8914
UR - https://doi.org/10.11648/j.ccr.20240802.12
AB - It was carried out a study on peripartum cardiomyopathy (PPCM) in the cardiology and internal medicine department of the University Hospital Center of Brazzaville. This work takes place from May 1, 2019 to April 31, 2023. It had aimed at identifying the profile of peripartum cardiomyopathy in women disadvantaged in cardiovascular diseases. Fifty-two files were selected on the basis of predefined inclusion criteria. The frequency of myocardiopathy peripartum was estimated at 1.4% of admissions and 9.7% of women of childbearing age, or 13 cases per year. The average age of the patients was 30.78.02 (range: 16 to 44 years), the most frequently found risk factors were respectively high low level socio-economic (77%), multiparity (36%); pregnancy-induced hypertension (32%) and anemia (31%). clinical picture was stereotypical and included signs of heart failure. This one was global in thirty-nine (39) cases (75%), left in thirteen (13) cases (25%), cardiomegaly was noted in all cases with mean cardiothoracic ratio at 0.614 (range 0.52 to 0.83). Sinus tachycardia was observed in fifty-one 51 cases (98%). Left atrial dilatation was noted in twenty-three 23 cases (44.2%), left atrial dilatation was noted in thirteen (13) cases (25%). Diffuse disorders of the repolarization were noted in forty-three cases (83%). Echocardiography revealed: left cavitary dilatation in 100% of cases; thrombosis left ventricular intravenous was noted in two cases (4%).
VL - 8
IS - 2
ER -
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