Individualized decision-making in severe peripartum cardiomyopathy: lactation, imaging, and the sequencing of guideline-directed therapy

PPCM is a rare, potentially life-threatening form of heart failure that develops in late pregnancy or the early postpartum period. Its management requires decisions beyond pharmacology alone, concerning both the extent of diagnostic investigation and whether to continue breastfeeding. A 30-year-old White woman, gravida 2, para 2, was admitted 23 days after an elective cesarean section with progressive breathlessness, bilateral pleural effusions, and severe left ventricular dilata-tion (end-diastolic diameter 58 mm, end-systolic diameter 42 mm; ejection fraction 30%, global longitudinal strain −9%). Natriuretic peptide and troponin were markedly elevated, and PPCM was diagnosed on clinical and echocardiographic grounds (NYHA class III). Breastfeeding was dis-continued for clinical and therapeutic reasons. After initial diuretic and beta-blocker treatment, sacubitril–valsartan, dapagliflozin, and eplerenone were introduced as part of guideline-directed therapy; eplerenone was later withdrawn for hyperkalemia. Cardiac magnetic resonance was not required for diagnosis. Coronary imaging was withheld because the pretest probability of coronary disease was very low. Clinical improvement was apparent within days. Serial echocardiography showed ejection fraction recovery to 41% at discharge, 46% at three months, and normalization to 65% at 10 months. Natriuretic peptide and troponin concentrations declined progressively and normalized by 10 months. Symptoms resolved fully, and the patient returned to normal physical activity. Recovery was sustained through 24 months of follow-up, during staged de-escalation of therapy. Decisions in severe PPCM can be individualized while remaining consistent with current guidance. Complete left ventricular function recovery was observed; however, it is unclear whether this was due to the treatment strategy or spontaneous resolution.