Severe Peripartum Cardiomyopathy With Complete Functional Recovery: The Role of Multimodality Imaging and Optimized Medical Therapy

Peripartum cardiomyopathy (PPCM) is a life-threatening, idiopathic form of heart failure with a highly variable recovery trajectory. While normalization of the left ventricular ejection fraction (LVEF) is frequently achieved, identifying residual myocardial injury and subclinical dysfunction remains a significant diagnostic challenge. A 25-year-old woman presented with acute heart failure seven weeks postpartum, following a pregnancy complicated by preeclampsia. Initial multimodality imaging revealed severe biventricular dysfunction (LVEF 14%, right ventricular ejection fraction 17%), intracavitary apical thrombi at the left ventricular apex, and a peak NT-proBNP of 12,241 pg/mL. Comprehensive management included therapeutic anticoagulation (initially with bemiparin), early guideline-directed medical therapy, and a prolonged 12-week course of bromocriptine. At the 18-month follow-up, the patient achieved complete clinical recovery (New York Heart Association (NYHA) class I) with normalization of LVEF. However, advanced imaging identified persistent subclinical impairment, evidenced by an abnormal global longitudinal strain (averaging -15.0%) and focal myocardial fibrosis (3% of total mass) on cardiac magnetic resonance. This case illustrates that clinical and conventional echocardiographic recovery in PPCM may mask persistent subclinical myocardial dysfunction. It emphasizes the necessity of multimodality imaging, specifically speckle-tracking strain analysis and tissue characterization, to accurately define the true spectrum of myocardial recovery and guide long-term risk stratification.