57. Case Report: Peripartum Cardiomyopathy with Cardiogenic Shock University of Pennsylvania
CardioNerds\xa0(Amit Goyal\xa0&\xa0Daniel Ambinder) join Penn cardiology fellows (Brian McCauley, Norrisa Haynes, and Mahesh Vidula) for a rooftop picnic in sunny Philadelphia! They discuss an informative case of peripartum cardiomyopathy with cardiogenic shock. Program director Dr. Frank Silvestry provides the E-CPR segment and a message to applicants. Johns Hopkins internal medicine resident\xa0Colin Blumenthal\xa0with mentorship from University of Maryland cardiology fellow\xa0Karan Desai.\xa0 \n\n\n\n\n\nJump to: Patient summary - Case figures & media - Case teaching - References - Production team\n\n\n\nEpisode graphic by Dr. Carine Hamo\n\n\n\n\n\n\n\nThe\xa0CardioNerds Cardiology Case Reports\xa0series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an\xa0\u201cExpert CardioNerd Perspectives & Review\u201d (E-CPR)\xa0for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.\n\n\n\nWe are teaming up with the\xa0ACC FIT Section\xa0to use the\xa0#CNCR episodes\xa0to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an\xa0E-CPR\xa0segment and a message from the program director.\n\n\n\nCardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza\n\n\n\n\n\n\n\n\n\n\n\nPatient Summary\n\n\n\nTwo weeks postpartum, a woman in her mid 20s, G1P1, with no past medical history presented\xa0following\xa0a tonic-clonic\xa0seizure.\xa0Prior\xa0to this, she had been experiencing 1 week of worsening dyspnea and lower extremity edema.\xa0Initial work-up revealed\xa0a\xa0left\xa0MCA stroke and\xa0she\xa0underwent thrombectomy. Limited TTE found\xa0LVEF <20% and a LV apical thrombus; she was\xa0started on milrinone due to concern for cardiogenic shock and transferred to the University of Pennsylvania.\xa0\n\n\n\nUpon arrival, she was found to be hypotensive and tachycardic. Exam\xa0was\xa0notable for elevated JVP, +S3, LE edema and R sided hemiparesis. Labs\xa0showed multiorgan injury, elevated NT-proBNP\xa0and\xa0elevated\xa0lactate. EKG demonstrated sinus tachycardia with no ST-T changes. Formal TTE\xa0showed\xa0severely dilated LV with EF 10%,\xa0diffuse LV hypokinesis,\xa0and\xa0confirmed\xa0a large LV apical thrombus. A pulmonary artery catheter was placed\xa0for tailored therapy and found elevated\xa0L-sided > R-side filling pressures\xa0with low cardiac index\xa0despite\xa0inotropes. Cardiac power output (CPO)\xa0was severely decreased\xa0with borderline pulmonary artery\xa0pulsatility\xa0index (PAPI),\xa0corroborating\xa0left\xa0>\xa0right heart failure. Patient ultimately required a\xa0durable\xa0left ventricular assist device (LVAD). Over the course of 9 months her guideline directed medical therapy (GDMT) was titrated and her intrinsic cardiac function\xa0and symptoms\xa0improved. Her EF improved to 35-40% and she tolerated an LVAD\xa0weaning protocol,\xa0so her LVAD was ultimately explanted! She is currently doing well on GDMT alone!\xa0\xa0\n\n\n\n\n\n\n\n\nCase Media\n\n\n\n\nCXR: Mild interstitial edema, +ET tubeST (131), LAD, nonspec T wave flattening, nl intervalsClick to Enlarge\n\n\n\n\n\n\n\n\n\n\n\n\n\nTTE 1\n\n\n\n\n\nTTE 2\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nEpisode Schematics & Teaching\n\n\n\nClick to enlarge!\n\n\n\n\n\n\n\nThe CardioNerds 5! \u2013 5 major takeaways from the #CNCR case\n\n\n\n1. How do we define Peripartum Cardiomyopathy?\xa0\xa0\n\n\n\nDiagnosis is made by\xa0the development of heart failure towards the end of pregnancy or in the months following delivery (~5 months postpartum), no other identifiable cause of HF, and demonstration of LV systolic dysfunction with LVEF typically less...