(192) Considerations for Transplant Psychiatry Evaluation: Peripartum Cardiomyopathy

Abstract:

Background: The diagnosis of peripartum cardiomyopathy (PPCM) is often delayed in young women, whose symptoms are initially attributed to pregnancy (Davis et al., 2020). This delay in diagnosis can result in distrust in healthcare providers and psychological distress, consequently translating to poor health behavior. For patients with PPCM in need of advanced cardiac therapies, such as left ventricular assist device (LVAD) or heart transplant, this psychological consequence of delayed diagnosis must be taken into consideration during their psychiatric evaluation. In this poster, we present a case of a patient who received a delayed diagnosis of PPCM and developed a trauma response, resulting in avoidance of care. We highlight the importance of a nuanced psychiatry evaluation on their health outcome.

Case Description: Patient is a 35-year-old female with a history of PPCM status-post LVAD implantation, major depressive disorder, and panic disorder, who presented with worsening heart failure requiring urgent transplant evaluation. Outpatient LVAD coordinators expressed significant concern due to the patient’s history of inconsistent compliance with required laboratory tests (ex: INR monitoring). During Transplant Psychiatry assessment, it became apparent that the patient’s lack of adherence was not secondary to disregard of medical advice, but more consistent with avoidance secondary to PTSD symptoms associated with her local hospital that missed a timely diagnosis of PPCM. Transplant Psychiatry recommended that the patient participate in trauma-focused psychotherapy to address her avoidance behaviors and improve her coping mechanisms to increase chance of successful transplant. After transplant, the patient has had a notable improvement in treatment adherence and continues to do well both psychiatrically and medically, with no evidence of rejection.

Discussion: PPCM often requires urgent admission, extensive workup, and carries a significant risk of mortality (Davis, 2020). Unfortunately, nearly 40% of women with PPCM experience symptom dismissal by health care providers, while up to 25% of women are initially given inaccurate diagnoses (Dekker, 2016). Delay in diagnosis may result in a heightened sense of vulnerability as patients are more likely to experience negative medical outcomes and preventable complications (Fett, 2013). Consequent distrust in healthcare systems is associated with increasing depression, reduced coping skills, and disengagement from care (Gupta, 2013). This is significant in transplant psychiatry, as eligibility for advanced treatment is often dependent on the patient’s ability to be reliable for extensive follow-up care. Transplant-psychiatrists should be familiar with the psychological challenges associated with PPCM to help patients optimize health-promoting behaviors by addressing underlying trauma.

Conclusion: This case report highlights the need for a nuanced transplant evaluation sensitive to the psychological burden of patients with PPCM and specifically cautions against the misinterpretation of non-adherence as disinterest in care, as maladaptive behavior may be reflective of an underlying trauma-response associated with delay in diagnosis.

Presenting Author(s)

SB

Shreya Bhasin, BA

Medical Student
University of Rochester
Rochester, New York, United States

Co-Author(s)

Joy Choi, MD

Senior Instructor in Psychiatry
University of Rochester Medical Center
Rochester, New York, United States