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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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Abstract:

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:  Akanksha21agr@gmail.com

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.

URL: 

https://rcm.imrpress.com/EN/10.31083/j.rcm.2019.02.55     OR     https://rcm.imrpress.com/EN/Y2019/V20/I2/53

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.,
2002

Japan
23 1 Palpitation,
nocturnal dyspnea,
orthopnea
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
Bangladesh
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
Canada
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.,
2013

Japan
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.,
2014

India
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.,
2014

India
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
Canada
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
USA
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
Japan
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
Canada
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
USA
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
India
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
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