Myocardial recovery in peri-partum cardiomyopathy after continuous flow left ventricular assist device

Peri-partum cardiomyopathy (PPCM) affects one in 300 to one in 100,000 pregnant patients, depending on ethnic origin [1]. Risk factors include previous episode of PPCM, multiparity and African ancestry. Causes are poorly understood but prolactin and/or immune-mediated mechanisms may be important. Therapy is supportive although specific therapy with bromocriptine may be beneficial. Prognosis is variable. In those that survive without transplantation, LVEF may improve but generally does not normalize [1].In non-ischemic cardiomyopathy, myocardial injury may be reversible. Sustained LV unloading from pulsatile devices coupled with aggressive reverse-remodeling pharmacologic therapy, possibly together with the β2-agonist clenbuterol (the HARPS protocol), may permit reversal of the molecular, cellular and structural remodeling seen in HF, and clinical recovery [2]. However, in most reports, recovery is rare and often not sustained [3,4], and PPCM and severe mitral regurgitation have not been studied [2,5]. Recovery is thought to occur mainly with pulsatile devices, but recently the HARPS protocol with clenbuterol achieved success also with continuous flow devices [5].Recovery with device and prognosis after explant are unpredictable. Prior to implantation, younger age and shorter duration of HF but not LVEF or LVEDD predict recovery [4,6]. Assessment of recovery requires turning the LVAD "off". Our protocol for the HeartMate II entails ensuring an INR ≥ 2.0, titrating down to 8,000 rpm, administering intravenous heparin (200 units/kg) and ensuring an activated clotting time > 400 at all times that the rpm is below 8,000, followed by gradual titration down to 6,000 rpm. This pump speed approximates zero forward flow [7]. Echocardiography, invasive hemodynamics and the cardiopulmonary exercise test are performed at 6,000 rpm and LVEF > 45 and LVEDD < 55 mm coupled with preserved hemodynamics suggest recovery [4,6]. The HARPS criteria have been established as criteria for r