Peripartum cardiomyopathy (PPCM) is a rare but life-threatening condition that occurs in late pregnancy or early postpartum and leads to heart failure with reduced left ventricular ejection fraction (LVEF). A severe complication of PPCM is cardiogenic shock, and its incidence has increased in the recent years. We conducted a retrospective multicenter cohort analysis to evaluate the 180-day clinical outcomes of PPCM complicated by cardiogenic shock (PPCM-CS), with a focus on the role of mechanical circulatory support. We identified 733 patients diagnosed with PPCM-CS between January 2010 and January 2024 using TriNetX, a multi-institutional U.S. health record database. Subgroup analysis evaluated outcomes among patients with no mechanical circulatory support (MCS), those managed with intra-aortic balloon pump (IABP) or percutaneous left ventricular assist device (pLVAD), and those supported with extracorporeal membrane oxygenation (ECMO). At 180-day follow-up, all-cause mortality of overall cohort was 15.8%, with higher mortality observed in ECMO (24.1%) and IABP/pLVAD (18.7%) groups. Durable LVAD implantation occurred in 15.0% of the overall cohort, with higher prevalence in ECMO (17.7%) and IABP/pLVAD (29.0%) groups. Heart transplantation was performed in 12.9% of the overall cohort, with higher prevalence in ECMO (19.0%) and IABP/pLVAD (27.1%) patients. Data on outcomes in patients with PPCM complicated by cardiogenic shock remain limited. This study offers insight into the 180-day outcomes in this high-risk population and suggests that, although MCS is associated with higher mortality, it may serve as a viable bridge to advanced therapies.
Peripartum cardiomyopathy (PPCM) is a life-threatening cardiac condition that manifests in late pregnancy or months following delivery and has the potential to precipitate heart failure (HF) with reduced left ventricular ejection fraction (LVEF). , The incidence is approximately 1 in 1,000 live births, with a higher incidence among Black women. The pathophysiology underlying PPCM is not fully elucidated. A leading hypothesis proposes that abnormal cleaving of prolactin resulting in proinflammatory, proapoptotic, and vasculotoxic effects, ultimately resulting in myocardial dysfunction. Echocardiography is the imaging modality used for evaluating suspected PPCM and may demonstrate moderate-to-severe left ventricular (LV) systolic dysfunction with or without LV dilation, mitral and tricuspid regurgitation, biatrial enlargement, elevated pulmonary artery pressures, and right ventricular (RV) enlargement. Although some studies have proposed strict criteria for diagnosis, usually LV systolic dysfunction in the absence of other forms of cardiomyopathy is sufficient to establish the diagnosis.
PPCM is associated with a range of complications including thromboembolic events (e.g., stroke), arrhythmias, chronic HF, cardiogenic shock (CS), and death. , Management of PPCM consists of guideline-directed medical therapy (GDMT) for heart failure, diuretics for pulmonary or systemic congestion, and inotropes for shock. While approximately half of patients achieve myocardial recovery (commonly defined as an improvement in LVEF to ≥ 50%), others may progress to CS requiring mechanical circulatory support (MCS). In the recent years, the incidence of CS identified in patients with PPCM has increased from 1.0% in 2004 to 2.2% in 2011. MCS utilization in this patient population has concomitantly increased from 0.9% in 2004 to 2.2% in 2011. Examples of MCS include percutaneous left ventricular assist device (pLVAD) such as Impella TM, intra-aortic balloon pump (IABP), and venoarterial (VA) and VV (venovenous) extracorporeal membrane oxygenation (ECMO). ,,, The 2022 AHA/ACC/HFSA guidelines provided a class IIa recommendation for temporary MCS in patients with acute decompensated HF, however, specific recommendations regarding MCS use in peripartum cardiomyopathy complicated by cardiogenic shock (PPCM-CS) are lacking.
Given the increasing incidence of PPCM-CS, we conducted a retrospective analysis of patient demographics, comorbidities, clinical outcomes, and utilization of advanced therapies between January 2010 and January 2024. In this study, we evaluated the clinical outcomes of patients with PPCM-CS, with a focus on the role of MCS in relation to mortality and/or serving as a bridge to advanced therapies such as durable left ventricular assist device (LVAD) or heart transplantation.
Methods
Data source
This study utilized a real-world, electronic health record (EHR)-based dataset from TriNetX, LLC. This database aggregates health records from health networks across the United States including large academic hospitals, community hospitals, and specialty practices. TriNetX database includes deidentified data for over 150 million patients across the country. Data integrity is maintained through routine, rigorous quality assessments to ensure the validity of each entry, as previously described in studies using this dataset. , The data has been deidentified in accordance with section 164.514(a) of the Health Insurance Portability and Accountability Act (HIPAA) Primary Rule. Thus, the study was deemed exempt from the Institutional Review Board (IRB) at the University of Alabama at Birmingham.
Study population
We conducted a retrospective cohort study of patients with PPCM-CS using data extracted from TriNetX between January 1 st, 2010 to January 31 st, 2024. We identified female patients over the age of 18 years with concomitant inpatient diagnoses of “peripartum cardiomyopathy” (ICD-10-CM:O90.3) and “cardiogenic shock” (ICD-10-CM:R57.0); the date of concurrent diagnosis was designated as the index date. The overall cohort comprised of 733 patients.
We conducted a separate analysis of 3 groups based on the utilization of mechanical circulatory support use within 180 days of index date. These groups were defined as (1) non-MCS group (n = 504), (2) IABP/pLVAD cohort (n = 107), and (3) ECMO group (n = 79) ( Figure 1 ). Standardized coding systems, including ICD-10, SNOMED-CT, RxNorm, and CPT codes, were used to identify and define study characteristics and outcomes ( Supplementary Table 1 ). Data analysis was conducted on June 6 th, 2025.
Outcomes of peripartum cardiomyopathy with cardiogenic shock at 180-day follow-up. This figure displays the outcomes of peripartum cardiomyopathy with cardiogenic shock at 180-day follow-up. The highest prevalence of mortality was observed in the ECMO group at 24.1% followed by 18.7% in the IABP/pLVAD group and 13.5% in the non-MCS group. Furthermore, the IABP/pLVAD group had the highest prevalence of heart transplantation at 27.1% followed by ECMO supported subgroup at 19.0%.
Baseline characteristics
Comorbidities were classified as baseline characteristics if they were documented at any time up to 1 day prior to index day. Medication use in TriNetX is categorized using RxNorm, VA, or ATC codes, and reflects both current and historical medications as of index date ( Supplementary Table 2 ). Left ventricular ejection (LVEF) and laboratory parameters including B-type natriuretic peptide (BNP), creatinine, and troponin were based on most recent values from available for each patient in TriNetX. These markers were selected given prior evidence suggesting that initial LVEF, BNP, and troponin levels may be prognostic indicators of outcomes in patients with PPCM. ,
Outcomes
Outcomes were defined as diagnoses or interventions occurring within 180 days of the index event ( Supplementary Table 2 ). The primary outcome was defined as all-cause mortality over a 180-day follow-up period. Secondary outcomes were defined as acute kidney injury (AKI), new-onset atrial fibrillation or flutter which was determined by excluding patients with outcome prior to index event, ventricular tachycardia/fibrillation (VT/VF), cardiac arrest, cerebral infarction/transient ischemic attack (TIA). Additionally, secondary outcomes encompassed advanced therapies including IABP/pLVAD and ECMO support (in cohort analysis only), durable LVAD implantation, and heart transplantation (HT) in both cohort analysis and subgroup analysis.
Statistical analysis
This was retrospective, descriptive study utilizing deidentified data from the TriNetX database. Continuous variables were reported as means with standard deviations, and categorical variables as frequencies with percentages. Clinical outcomes were reported as the proportion of patients experiencing each event within the respective groups. All primary and secondary outcomes were reported in the cohort and subgroup analysis, except ECMO support and IABP/pVAD support, which were not included in the subgroup analysis. Mortality status in TriNetX is determined through routine capture of the inpatient EHR, where patients are marked as “deceased”, and this information is regularly updated through monthly data refreshes from participating healthcare organizations. Most analyses were performed using embedded statistical tools within the TriNetX platform, which provides an embedded tool that utilizes a combination of Java, R, and Python for risk estimation and survival analysis. For the subgroup analysis, incidence rates (IR) for each clinical outcome were calculated on OpenEpi, and reported as incidence rates per 10 person-years. 95% confidence intervals were calculated using the Mid-P exact test.
Results
Baseline characteristics
The overall PPCM-CS cohort (n = 733) had a mean age of 33.9 years (SD 9.3). Nearly half of the cohort identified as Black/African American (46.5%), followed by White (40.1%), and Hispanic/Latino (8.2%). The most prevalent comorbidities included chronic systolic HF (38.6%), essential hypertension (38.3%), anxiety disorder (33.2%), asthma (19.4%), and type II diabetes mellitus (18.6%). Pre-eclampsia had a 10.8% incidence; however, eclampsia was not observed within any patients within our cohort ( Table 1 ).
Table 1
Baseline characteristics prior to diagnosis of peripartum cardiomyopathy with cardiogenic shock
| Overall PPCM-CS cohort (n = 733) |
Non-MCS group
(n = 504) |
IABP/pLVAD group (n = 107) |
ECMO group
(n = 79) |
|
|---|---|---|---|---|
| Demographics | ||||
|
Age at index,
Mean (SD) |
33.9 (9.3) | 34.4 (9.8) | 33.7 (8.5) | 32.3 (8.2) |
| Race/Ethnicity, No. (%) | ||||
| Hispanic/Latino | 60 (8.2) | 45 (8.9) | ≤10 | <10 |
| Black/African American | 341 (46.5) | 231 (45.8) | 51 (47.7) | 33 (41.8) |
| White | 294 (40.1) | 200 (39.7) | 46 (43.0) | 33 (41.8) |
| Presence of comorbidities, No. (%) | ||||
| Alcohol use disorder | 27 (3.7) | 20 (4.0) | ≤10 | <10 |
| Anxiety disorder | 243 (33.2) | 172 (34.1) | 56 (52.3) | 33 (41.8) |
| Asthma | 142 (19.4) | 100 (19.8) | 30 (28.0) | 20 (25.3) |
| CKD | 119 (16.2) | 87 (17.3) | 29 (27.1) | 20 (25.3) |
| Type II DM | 136 (18.6) | 103 (20.4) | 32 (29.9) | 16 (20.3) |
| Gestational DM | 62 (8.5) | 46 (9.1) | ≤10 | <10 |
| Gestational HTN | 47 (6.4) | 37 (7.3) | ≤10 | <10 |
| Pre-Eclampsia | 79 (10.8) | 62 (12.3) | ≤10 | <10 |
| Eclampsia | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Essential HTN | 281 (38.3) | 191 (37.9) | 55 (51.4) | 32 (40.5) |
| Hyperlipidemia | 122 (16.6) | 83 (16.5) | 21 (19.6) | 14 (17.7) |
| Hypothyroidism | 78 (10.6) | 57 (11.3) | 17 (15.9) | 12 (15.2) |
| Coronary artery disease | 94 (12.8) | 65 (12.9) | 24 (22.4) | 18 (22.8) |
| Chronic systolic HF | 283 (38.6) | 194 (38.5) | 59 (55.1) | 22 (27.8) |
| Chronic diastolic HF | 33 (4.5) | 26 (5.2) | ≤10 | <10 |
| Combined systolic/diastolic HF | 118 (16.1) | 81 (16.1) | 25 (23.4) | <10 |
| Atrial fibrillation/flutter | 112 (15.3) | 85 (16.9) | 35 (32.7) | 26 (32.9) |
| Neoplasms | 117 (16.0) | 80 (15.9) | 24 (22.4) | 16 (20.3) |
| Nicotine dependence | 134 (18.3) | 95 (18.8) | 29 (27.1) | 16 (20.3) |
| Cerebral infarction | 55 (7.5) | 37 (7.3) | 13 (12.1) | 20 (25.3) |
| TIA | 19 (2.6) | 12 (2.4) | ≤10 | <10 |
In the subgroup analysis, the ECMO group (n = 79) had the youngest mean age at 32.3 years (SD 8.2), followed by IABP/pLVAD group (33.7 years, SD 8.5) and non-MCS group (34.4, SD 9.8). Racial and ethnic distributions across groups is reported in Table 1 . The IABP/pLVAD group had highest observed prevalence of most comorbidities, including chronic systolic HF (55.1%), anxiety disorder (52.3%), essential hypertension (51.4%), and atrial fibrillation/flutter (41.8%). Similarly, the ECMO group also showed a substantial burden of comorbidities relative to the non-MCS group (n = 504) ( Table 1 ).
Among the overall PPCM-CS cohort, beta-blockers were the most frequently documented medication (59.3%), followed by spironolactone (43.2%), ACE inhibitors (41.3%), and angiotensin II receptor blockers (31.5%). Guideline-directed medical therapy appeared most documented in the IABP/pLVAD group, including beta-blockers (72.0%), spironolactone (62.6%), and ACE inhibitors (48.6%), with lower proportions observed in the non-MCS and ECMO groups. Mean left ventricular ejection fraction (LVEF) was lowest in the IABP/pLVAD group (17.7%, SD 7.9), followed by ECMO (23.0%, SD 19.2) and non-MCS (31.3%, SD 17.6). Mean troponin I levels were elevated in IABP/pLVAD (3.32 ng/mL) and ECMO (2.91 ng/mL) groups, relative to non-MCS group (0.257 ng/mL). Mean BNP levels were highest in the IABP/pLVAD group (1389 pg/mL), while the ECMO group had the highest mean creatinine level (1.41 mg/dL) ( Table 2 ).
Table 2
Medications, cardiac function, and laboratory values among patients with peripartum cardiomyopathy and cardiogenic shock
| Medication use, No. (%) | Overall cohort ( n = 733) | Non-MCS ( n = 504) | IABP/ pLVAD ( n = 107) | ECMO ( n = 79) |
|---|---|---|---|---|
| Beta-blockers | 435 (59.3%) | 309 (61.3%) | 77 (72.0%) | 44 (55.7%) |
| Angiotensin converting enzyme (ACE) inhibitors | 303 (41.3%) | 212 (42.1%) | 52 (48.6%) | 24 (30.4%) |
| Angiotensin receptor blockers (ARBs) | 231 (31.5%) | 165 (32.7%) | 44 (41.1%) | 17 (21.5%) |
| Calcium channel blockers | 143 (19.5%) | 105 (20.8%) | 21 (19.6%) | 25 (31.6%) |
| Spironolactone | 317 (43.2%) | 218 (43.3%) | 67 (62.6%) | 27 (34.2%) |
| Sodium-glucose Co-transporter 2 (SGLT2) inhibitors | 80 (10.9%) | 56 (11.1%) | 22 (20.6%) | 0 (0.0%) |
| Metformin | 65 (8.9%) | 52 (10.3%) | 10 (9.3%) | 0 (0.0%) |
| HMG-CoA reductase inhibitors | 133 (18.1%) | 90 (17.9%) | 34 (31.8%) | 14 (17.7%) |
| LVEF (%), Mean (SD) | 27.5 (16.8) | 31.3 (17.6) | 17.7 (7.9) | 23.0 (19.2) |
| Laboratory parameters, Mean (SD) | Overall cohort ( n = 733) | Non-MCS ( n = 504) | IABP/ pLVAD ( n = 107) | ECMO ( n = 79) |
| BNP, pg/mL | 1016 (1103) | 1037 (1110) | 1389 (1544) | 1116 (1006) |
| Creatinine, mg/dL | 1.15 (1.22) | 1.17 (1.35) | 1.15 (0.64) | 1.41 (1.07) |
| Troponin I, ng/mL | 0.32 (1.45) | 0.26 (1.48) | 3.32 (13.8) | 2.91 (6.65) |
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