Cardiac Graft Versus Host Disease: A Rare or Underrecognized Pathology?

Allogeneic hematopoietic stem cell transplantation is a potentially curative procedure for a variety of hematologic and immunologic disorders. Despite the powerful therapeutic potential, both acute, and chronic toxicities including graft versus host disease (GVHD) and cardiovascular disease can lead to significant short- and long-term morbidity and mortality. While GVHD can affect any organ, cardiac involvement is rarely described in the literature. In this review, we review available literature, and allude to pathophysiology and therapeutic approaches in cardiac GVHD.

Peripartum Cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure (HF) that affects women late in pregnancy or in the early puerperium. There are several definitions for PPCM. While there are numerous potential mechanisms for Peripartum (post-partum) cardiomyopathy, its exact cause remains unknown1, but the etiopathogenesis is likely to be multifactorial. PPCM is uncommon before 36 weeks of pregnancy, and afflicted women generally present during the first month after delivery. PPCM should be differentiated from pre-existing cardiomyopathy, undiagnosed congenital heart disease, pre-existing valvular heart disease, myocardial infarction, pulmonary embolism and diastolic heart failure due to hypertensive heart disease. The principles for treating acute HF caused by PPCM are the same as those for acute HF caused by any other cause with some limitations during pregnancy. Prompt treatment is critical. There is no necessity for an early delivery unless the maternal or foetal health has deteriorated. In women who present with advanced HF with haemodynamic instability, urgent delivery, regardless of gestation, may be considered. Because women with PPCM have a significant chance of relapse in subsequent pregnancies, they need comprehensive contraceptive counselling. In general, the prognosis is good, with more than half of the patients regaining LV function spontaneously within six months of giving birth. Our aim is to put forth an in-depth review of the Peripartum Cardiomyopathy in contemporary practice.

AMH and Its Clinical Implications.

Anti-Müllerian Hormone (AMH) is critical for physiologic involution of the Mullerian ducts during sexual differentiation in the male fetus. In women, AMH is a product of the small antral follicles in the ovaries and serves to function as an autocrine and paracrine regulator of follicular maturation. As the size of the residual follicular pool depends on the quantity of small antral follicles and declines over time, the serum AMH level in women follows a characteristic trajectory: a gradual decline throughout the reproductive years and a precipitous drop at menopause, becoming undetectable soon after. Thus, AMH is clinically useful as a screening tool for diminished ovarian reserve (Cui et al. in Fertil Steril 105(02):481-485, 2016). Perturbations in serum AMH are linked with a variety of pathological conditions, for instance, polycystic ovaries syndrome (PCOS), the pathophysiology likely being the excess follicles in this syndrome which produce increased amounts of AMH (Dumont et al. in Reprod Biol Endocrinol 13:137, 2015). AMH is also elevated in some ovarian tumors such as adult granulosa cell tumors, and it can be used as a tumor marker to gauge response to therapy and monitor for recurrence. Within the domain of assisted reproductive technology, serum AMH assays are widely used to derive prognostic information such as the chance of successful ovarian stimulation, subsequent embryo quality and even pregnancy rates. Finally, in the rapidly evolving field of oncofertility, serum AMH holds great promise as a predictor of ovarian reserve after completion of cancer therapy. Our aim is to put forth an in-depth review of the clinical applications of AMH in contemporary practice.