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Reviews in Cardiovascular Medicine  2019, Vol. 20 Issue (2): 53-58     DOI: 10.31083/j.rcm.2019.02.55
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Anticoagulation for intra-cardiac thrombi in peripartum cardiomyopathy: A review of the literature
Akanksha Agrawal1, *(), Deepanshu Jain2, Pradhum Ram1, Jorge Luis Penalver Leon1, Janani Rangaswami3
1 Department of Internal Medicine, Einstein Medical Center Philadelphia, PA
2 Department of Digestive Diseases and Transplantation, Einstein Medical Center Philadelphia, PA
3 Division of Nephrology, Department of Internal Medicine, Einstein Medical Center Philadelphia, PA
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Peripartum cardiomyopathy is a type of non-ischemic cardiomyopathy with a high rate of thromboembolic events. Guiding strategies for anticoagulation in patients with peripartum cardiomyopathy and thromboembolic events are limited. Literature for all cases of peripartum cardiomyopathy with intracardiac thrombi were reviewed and summarized from twelve case reports. Based on the available literature, we conclude that patients with peripartum cardiomyopathy with ejection fraction of less than 30% should strongly consider anticoagulation therapy to avoid thromboembolic events. Future studies may be able to further elucidate the optimal indication and duration of anticoagulation.

Key words:  Peripartum cardiomyopathy      thrombus      anticoagulation      
Submitted:  13 May 2019      Accepted:  20 June 2019      Published:  30 June 2019     
*Corresponding Author(s):  Akanksha Agrawal     E-mail:

Cite this article: 

Akanksha Agrawal, Deepanshu Jain, Pradhum Ram, Jorge Luis Penalver Leon, Janani Rangaswami. Anticoagulation for intra-cardiac thrombi in peripartum cardiomyopathy: A review of the literature. Reviews in Cardiovascular Medicine, 2019, 20(2): 53-58.

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Table 1  Descriptive summary of case reports (1-12) describing intracardiac thrombi in patients with PPCM.
Study, Year, Country Age of patient Gravidity Presentation Presentation post partum (PP) Mode of delivery LVEF (%) LVED diameter (cm) Location of thrombus Appearance/features of thrombus Anticoagulant used Clinical outcome Embolic episode Days for resolution of thrombus Follow up Echo EF (%) LVED diameter (cm) Total follow up period
Nishi et al.,

23 1 Palpitation,
nocturnal dyspnea,
6 weeks PP Vaginal 18 5.7 Apical thrombi in both ventricle spherical, pedunculate, shaggy and irregular in configuration, and freely mobile, suggesting that they were fresh IV heparin-->Warfarin Resolution of thrombus No 4 2 months 48 4.7 1 year
Kim et al., 2011
22 N/A Dyspnea, weakness 4 months PP Vaginal 17 6.4 Biventricular thrombi Larger in the RV, Smaller LV [Septal location] Subcutaneous Heparin and Warfarin Resolution of thrombus No Smaller LV- 16 days,
larger RV-21 days
2 months 17 N/A 2 months
Corriveau et al., 2014
29 3 Dyspnea, fatigue, orthopnea and LE edema 2 weeks PP Vaginal 16 N/A LV Large, mobile Heparin-->Warfarin N/A Yes-CVA N/A N/A N/A N/A N/A
Sakamoto et al.,

37 2 Dyspnea 4 months PP C-Section 29 6.5 1. LV apex
2. RV apex
Mobile, large [2.8 x 2 cm -Larger LV and 1.6 x 1 cm -RV] Heparin--> Warfarin Resolution of thrombus Yes-CVA N/A 1 year 62 4.8 13 months
Bagul et al.,

26 1 Dyspnea 8 days PP Vaginal 20 N/A 1. Apex
2. RV free wall
3. RA Roof
2.5 x 2 cm, 3.5 x 1 cm, 1 x 1cm IV heparin-->Warfarin Resolution of thrombus No 2 clots [smaller] -3 days;
1 larger [apex]- 1 month
1 month 40 N/A 1 month
Kharwar et al.,

30 4 Dyspnea, Orthopnea 3 weeks PP Vaginal 32 3.05 cm/m2 (LVEDD index) LV- Septum Pedunculated 2.5 x 2 cm Warfarin Resolution of thrombus No 1 month 1 month 43 N/A N/A
Altuwaijri et al., 2012
25 4 Dyspnea, Orthopnea, PND 7 months PP N/A <20 N/A Multiple LV, lateral wall large layered echodense mass Heparin Resolution of thrombus No 4 days N/A N/A N/A N/A
Box et al., 2004
31 N/A Edema, Fatigue 4 weeks PP Vaginal 20 6.9 LV Apex N/A N/A N/A Yes- coronaries N/A N/A N/A N/A 6 months
Shimamoto et al., 2008
32 2 N/A 10 days PP C-section 20 6 LV apical mural mass
--> development of 3 LV apical masses
35 X 20 mm (initially immobile--> mobile)
20X9, 10X10, 10X10 --> immobile
Warfarin +Heparin--> Warfarin Needed surgical removal as it became mobile No 24 days 30 days 33 5.5 2 years
Kaufman et al., 2003
38 7 Acute dyspneoa 30 weeks gestation C-section 45 N/A Lt MCA thrombi N/A heparin--> Warafarin Improved clinically Yes- CVA N/A N/A N/A N/A N/A
Ibebuogu et al., 2007
24 5 Epigastric, RUQ pain, Nausea, Vomiting 5 months PP Vaginal <15 6.5 LV anterior wall thrombus--> BiV thombi N/A Yes (not mentioned what kind) Underwent b/l LE thrombectomy Yes- liver, bilateral kidneys, common iliac and right external iliac arteries 5 days N/A N/A N/A 2 weeks
Bhat et al., 1986
20 N/A Exertional SOB, Fatigue, Palpitation, PND 4 months PP Vaginal 39 6.5 Biventricular apices N/A Heparin--> oral AC Underwent bilateral femoral thromboembolectomy Yes- bilateral femoral artery NA N/A N/A N/A N/A
Altuwaijri, W. A., Kirkpatrick, I. D., Jassal, D. S. and Soni, A . ( 2012) Vanishing left ventricular thrombus in a woman with peripartum cardiomyopathy: a case report. BMC Research Notes 5, 1-3.
doi: 10.1186/1756-0500-5-1
Amos, A. M., Jaber, W. A. and Russell, S. D . ( 2006) Improved outcomes in peripartum cardiomyopathy with contemporary. American Heart Journal 152, 509-513.
doi: 10.1016/j.ahj.2006.02.008
Arany, Z. and Elkayam, U . ( 2016) Peripartum Cardiomyopathy. Circulation 133, 1397-1409.
doi: 10.1161/CIRCULATIONAHA.115.020491
Azibani, F. and Sliwa, K . ( 2018) Peripartum Cardiomyopathy: an Update. Current Heart Failure Reports 15, 297-306.
Bagul, P. K., Phadke, M. S., Pahwa, J. S., Sharma, R. B., Lanjewar, C. P. and Kerkar, P. G .( 2014) Three vanishing masses in the heart. Journal of Cardiology Cases 10, 19-21.
Baughman, K. L . ( 2006) Management of a case of peripartum cardiomyopathy. Nature Clinical Practice Cardiovascular Medicine 3, 514-518.
Bhat, P. S., Kattakkayam, T. Sr., Shah, R. K., Reddy, M. M. and Narayanan, G. R . ( 1986) Peripartum cardiomyopathy with biventricular thrombi presenting as acute saddle embolism. A case report. Indian Heart Journal 38, 486-488.
Box, L. C., Hanak, V. and Arciniegas, J. G . ( 2004) Dual coronary emboli in peripartum cardiomyopathy. Texas Heart Institute Journal 31, 442-444.
Corriveau, S., Cooray, M. and Douketis, J . ( 2014) To thin or not to thin: A case of peripartum cardiomyopathy. Canadian Journal of Cardiology 30 1.e1- 1.e2.
Damorou, F.J., Kane, A., Napporn, G., Thiam, O., Bidani, A., Diop, I.B., Sarr, M., Ba, S.A. and Diouf, S.M . ( 2000) Biventricular thrombus complicating peripartum cardiomyopathy. A case report. Dakar medical 45, 199-201.
Elkayam, U., Tummala, P. P., Rao, K., Akhter, M. W., Karaalp, I. S., Wani, O. R., Hameed, A., Gviazda, I. and Shotan, A . ( 2001) Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy. The New England Journal of Medicine 344, 1567-1571.
doi: 10.1056/NEJM200105243442101
Elkayam, U . ( 2011) Clinical characteristics of peripartum cardiomyopathy in the United States: diagnosis, prognosis, and management. Journal of the American College of Cardiology 58, 659-670.
doi: 10.1016/j.jacc.2011.03.047
Fett, J. D., Christie, L. G., Carraway, R. D. and Murphy, J. G . ( 2005) Five-year prospective study of the incidence and prognosis of peripartum cardiomyopathy at a single institution. Mayo Clinic Proceedings 80, 1602-1606.
doi: 10.4065/80.12.1602
Gerald, G. Briggs., Roger, K. Freeman. and Sumner, J. Y . ( 2009) Drugs In Pregnancy and Lactation (8th Edition), Wolters Kluwer, Philadelphia, PA.
Hellgren, M . ( 2003) Hemostasis during normal pregnancy and puerperium. Semin Thromb Hemost 29, 125-130.
doi: 10.1055/s-2003-38897
Hilfiker-Kleiner, D., Haqhikia, A., Berliner., D., Vogel-Claussen, J., Schwab, J., Franke, A., Schwarzkopf, M., Ehlermann, P., Pfister, R., Westenfeld, G. M. R., Stangl, V., Kindermann, I., Kühl., U., Angermann, C. E., Schlitt, A., Fischer, D., Böhm, E. P. M., Sliwa, M. and Bauersachs, J . ( 2017) Bromocriptine for the treatment of peripartum cardiomyopathy: a multicenter randomized study. European Heart Journal 38, 2671-2679.
doi: 10.1093/eurheartj/ehx355
Hopp, L., Haider, B. and Iffy, L . ( 1996) Myocardial infarction postpartum in patients taking bromocriptine for the prevention of breast engorgement. International Journal of Cardiology 57, 227-232.
doi: 10.1016/S0167-5273(96)02789-1
Ibebuogu, U. N., Thornton, J. W. and Reed, G. L . ( 2007) An unusual case of peripartum cardiomyopathy manifesting with multiple thrombo-embolic phenomenon. Thrombosis Journal 5, 1-5.
doi: 10.1186/1477-9560-5-1
Johnson-Coyle, L., Jensen, L. and Sobey, A . ( 2012) Peripartum cardiomyopathy: review and practice guidelines. American Journal of Critical Care 21, 89-98.
doi: 10.4037/ajcc2012163
Kaufman, I., Bondy, R. and Benjamin, A . ( 2003) Peripartum cardiomyopathy and thromboembolism; anesthetic management and clinical course of an obese, diabetic patient. Canadian Journal of Anesthesia 50, 161-165.
doi: 10.1007/BF03017850
Kharwar, R. B., Chandra, S., Dwivedi, S. K. and Saran, R. K . ( 2014) A pedunculated left ventricular thrombus in a women with peripartum cardiomyopathy: evaluation by three dimensional echocardiography. J Cardiovasc Ultrasound 22, 139-143.
doi: 10.4250/jcu.2014.22.3.139
Kim, D. Y., Islam, S., Mondal, N. T., Mussell, F. and Rauchholz . ( 2011) Biventricular Thrombi Associated with Peripartum Cardiomyopathy. Journal of Health, Population and Nutrition 29, 178-180.
Kido, K. and Guglin, M . ( 2019) Anticoagulation therapy in specific cardiomyopathies: isolated left ventricular noncompaction and peripartum cardiomyopathy. Journal of Cardiovascular Pharmacology and Therapeutics 24, 31-36.
doi: 10.1177/1074248418783745
Koç, M., Sahin, D.Y., Tekin, K. and Caylı, M . ( 2011) Development of biventricular large apical thrombi and cerebral embolism in young woman in peripartum cardiomyopathy. Türk Kardiyol Dern Arş 39, 591-594.
doi: 10.5543/tkda.2011.01534
Kolte, D., Khera, S., Aronow, W. S., Palaniswamy, C., Mujib, M., Ahn, C., Jain, D., Gass, A., Ahmed, A., Panza, J. A. and Fonarow, G. C . ( 2014) Temporal trends in incidence and outcomes of peripartum cardiomyopathy in the United States: a nationwide population-based study. Journal of the American Heart Association 3, 1-13.
LaRue, S., Shanks, A., Wang, I., Ewald, G., Anderson, D. and Joseph, S . ( 2011) Left ventricular Assist Device in Pregnancy. Obstetrics & Gynecology 118, 426-428.
Loewe, C. and Dragovic, L. J . ( 1998) Acute coronary artery thrombosis in a postpartum woman receiving bromocriptine. The American Journal of Forensic Medicine and Pathology 19, 258-260.
doi: 10.1097/00000433-199809000-00012
McNamara, D. M., Elkayam, U., Alharethi, R., Damp, J., Hsich, E., Ewald, G., Modi, K., Alexis, J.D., Ramani, G.V., Semigran, M. J., Haythe, J., Markham, D. W., Marek, J., Gorcsan, J. 3rd., Wu, W. C., Lin, Y., Halder, I., Pisarcik, J., Cooper, L. T., Fett, J. D. and IPAC, Investigators . ( 2015) Clinical Outcomes for Peripartum Cardiomyopathy in North America. Journal of the American College of Cardiology 66, 905-914.
doi: 10.1016/j.jacc.2015.06.1309
Mikami, T. and Kamiunten, H . ( 2018) Emergent caesarian section under mechanical circulatory support for acute severe peripartum cardiomyopathy. Journal of Cardiology Cases 17, 200-203.
doi: 10.1016/j.jccase.2018.02.002
Napporn, A. G., Kane, A., Damorou, J. M., Dia, A. A., Diop, I. B., Sarr, M., Ba, S.A. and Diouf, S.M . ( 2000) Intraventricular thrombosis complicating peri-partum idiopathic myocardiopathy. Annales de Cardiologie et D'angeiologie 49, 309-314.
Nishi, I., Ishimitsu, T., Ishizu, T., Ueno, Y., Suzuki, A., Seo, Y., Ohtsuka, S., Iida, K. and Yamaguchi, I . ( 2002) Peripartum Cardiomyopathy and Biventricular thrombi. Circulation Journal 66, 863-865.
doi: 10.1253/circj.66.863
Pearson, G. D., Veille, J., Rahimtoola, S., Hsia, J., Oakley, C. M., Hosenpud, J. D., Ansari, A. and Baughman, K. L . ( 2000) Peripartum Cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) Workshop Recommendations and Review. JAMA 283, 1183-1188.
doi: 10.1001/jama.283.9.1183
Seeland, U., Bauercashs, J., Roos-Hesselink, J. and Regitz-Zagrosek, V . ( 2018) Update of the ESC guidelines 2018 on cardiovascular diseases during pregnancy: Most important facts. Herz 43, 710718.
Sánchez-Rubio Lezcano, J., Galache Osuna, J.G., Marquina Barcos, A., Calvo Cebollero, I., Diarte de Miguel, J.A. and Placer Peralta, L.J . ( 2004) Peripartum cardiomyopathy with biventricular thrombi. Anales de Medicina Interna 21, 498-500.
Sakamoto, A., Hosoya, N., Kageyama, S., Yoshizaki, T., Takeuchi, R., Murata, K., Nawada, R., Onodera., T., Takizawa, A., Nonaka, Y. and Fukasawa, S . ( 2013) Peripartum cardiomyopathy with biventricular thrombus which led to massive cerebral embolism. Journal of Cardiology Cases 9, 71-74.
Shimamoto, T., Marui, A., Oda, M., Tomita, S., Nakajima, H., Takeuchi, T. and Komeda, M . ( 2008) A case of peripartum cardiomyopathy with recurrent left ventricular apical thrombus. Circulation Journal 72, 853-854.
doi: 10.1253/circj.72.853
Sliwa, K., Forster, O. and Libhaber, E . ( 2006) Peripartum cardiomyopathy: inflammatory markers as predictors of outcome in 100 prospectively studied patients. European Heart Journal 27, 441-446.
doi: 10.1093/eurheartj/ehi481
Sheppard, R., Rajagopalan, N., Safirstein, J. and Briller, J . ( 2014) An update on treatments and outcomes in peripartum cardiomyopathy. Future Cardiology 10, 435-447 .
doi: 10.2217/fca.14.23
Writing Committee, M., Yancy, C.W., Jessup, M., Bozkurt, B., Butler, J., Casey DE, J. r., Drazner, M. H., Fonarow, G. C., Geraci, S. A., Horwich, T., Januzzi, J. L., Johnson, M. R., Kasper, E. K., Levy, W. C., Masoudi, F. A., McBride, P. E., McMurray, J. J., Mitchell, J. E., Peterson, P. N., Riegel, B., Sam, F., Stevenson, L.W., Tang, W. H., Tsai, E. J. and Wilkoff, B. L ., American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. ( 2013) 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on practice guidelines. Circulation 128, e240-e327.
Zehir, R., Karabay, C. Y., Kocabay, G., Kalayci, A., Akgun, T. and Kirma, C . ( 2014) An unusual presentation of peripartum cardiomyopathy: recurrent transient ischemic attacks. Revista Portuguesa de Cardiologia 33, 561.e1- 561. e3
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