1. What’s New with Peripartum Cardiomyopathy?
Philippine Heart Association
43rd Annual Convention & Scientific Meeting
Bringing Global Trends in Cardiology Closer to Home
What’s New with Peripartum Cardiomyopathy?
Albert Hans P. Bautista, MD, FPCP, FPCC
The Medical City
Session:
Cardiomyopathy and Cor Pulmonale
Friday, May 25, 2012; 2:00-2:30
Sapphire B, Crowne Plaza Hotel

2. Disclosures
- Received honorarium for lectures on various cardiovascular topics - hypertension, ACS, anti-platelet /anti-coagulation & CHF for various pharmaceutical companies.
Received research grants or honorarium for various clinical trials on hypertension, anti-platelet, anti-coagulation, ACS & CHF patients for various pharmaceutical companies.
Member of the Advisory Board for Thrombosis of Sanofi

3. PERIPARTUM CARDIOMYOPATHY?
Session Outline
What’s New in
PERIPARTUM CARDIOMYOPATHY?
- Review the cardiovascular changes in pregnancy
Pathophysiology of PPCM
History, PE and Diagnosis of PPCM
Treatment of PPCM
I did a free-text search on PubMed for the search term Cardiomyopathy and it yielded over 80,000 hits. I followed this with a search for peripartum which yielded a little over 2000 hits. The combination of the 2 search terms with AND plus filters for English and human studies narrowed the hits to 269. Still a lot of journals but at least manageable. Looked into what’s new and for new therapeutic options.

4. PERIPARTUM CARDIOMYOPATHY?
Session Outline
What’s New in
PERIPARTUM CARDIOMYOPATHY?
- Review the cardiovascular changes in pregnancy
Pathophysiology of PPCM
History, PE and Diagnosis of PPCM
Treatment of PPCM
And with this pubmed searches, I will be able to at least give you a few “what’s new” or at least something to think about.

5. Cardiovascular Changes in Pregnancy
To meet the increased metabolic demands of both the mother and fetus1,2 (evident by 5th to 8th wk, peak by late 2nd trimester)
> Increased blood volume (40%)
> Increased CO (30-50%)  80% early postpartum
> Decreased SVR & BP (active vasodilation)
> Increased LV size (30%, dilatation)
Hypercoagulopathy1
> Increased coagulation factors, fibrinogen & platelet adhesiveness
> Risk for thrombo-embolism from venous stasis due to
obstructing uterus
1) ESC Guidelines on the management of cardiovascular diseases during pregnancy.
European Heart Journal (2011) 32, 3147–3197
2) Oakley C et al Ed. Heart Disease in Pregnancy 2nd Ed. Massachusetts, Blackwell Publishing 2007:6-17

6. Cardiovascular Changes in Pregnancy
to meet the increased metabolic demands of both the mother and fetus1,2 (evident by 5th to 8th wk, peak by late 2nd trimester)
> Increased CO (30-50%)  benign early systolic ejection murmur
> Increased LV size (30%, dilatation)  displaced apex beat
> Increased Preload
(inc bld vol + CO)
> Decreased Afterload
(low resistance utero-
placental circulation
+ vasodilation)
1) ESC Guidelines on the management of cardiovascular
diseases during pregnancy.
European Heart Journal (2011) 32, 3147–3197
2) Oakley C et al Ed. Heart Disease in Pregnancy 2nd Ed. Massachusetts,
Blackwell Publishing 2007:6-17

7. Peripartum Cardiomyopathy: Pathophysiology
- Idiopathic cardiomyopathy presenting with heart failure 2ndary to LV systolic dysfunction from 1 month antepartum, up to 5 months after delivery, when no other causes of heart failure is evident3
- Incidence of 1:3004 to 1:40005 pregnancies
- Predisposing factors:5, 6, 7
> Multiparity
> multiple births
> Smoking, diabetes
> Pregnancy complicated by pre-eclampsia, eclampsia or hypertension
> Advanced age or teenage pregnancy
5) Pearson G et al. National Heart, Lung and Blood Institute and Office of Rare Diseases (National Institute of Health)
Workshop Recommendations and review. JAMA. 2000; 283 (9):
6) Sliwa K et al. Peripartum Cardiomyopathy. Lancet. 2006; 368 (9536):
7) Demakis JG et al. Natural course of peripartum cardiomyopathy. Circulation. 1971; 44 (6):
3) Elliott P, et al. Classification of the cardiomyopathies: a position statement from the European Society of Cardiology Working Group
on myocardial and pericardial diseases. Eur Heart J 2008; 29:
4) Fett JD et al. Five year prospective study of the incidence and prognosis of peripartum cardiomyopathy at a single institution.
Mayo Clin Proc 2005; 80 (12):

8. Peripartum Cardiomyopathy: Pathophysiology
- Etiology8 (Plausible etiologic mechanisms):
> Myocarditis
> Apoptosis & inflammation
> Abnormal immune response to pregnancy (Chimerism)
> Maladaptive response to hemodynamic stresses of pregnancy
> Others: Prolactin
8) Johnson-Coyle L, et al. Peripartum cardiomyopathy: Review and Practice Guidelines.
Am J Critical Care 2012; 21 (2): 89-98

9. Peripartum Cardiomyopathy: Pathophysiology
Etiology (Plausible etiologic mechanisms):
- Viral Myocarditis (Gouley et al 1937)
> % prevalence of myocarditis in PPCM9, 10
> Endomyocardial biopsy shows lymphocytic infiltrates w/ myocytic edema, necrosis & fibrosis11
- Apoptosis & inflammation
> programmed cell death
> Increased concentration of plasma cytokines: tumor necrosis factor a, CRP and Fas/Apo-1 (cell surface protein ligand role in apoptosis)12
> no significant correlation has been demonstrated to LV function13
9) Midei MG et al. Peripartum myocarditis and cardiomyopathy. Circulation. 1990; 81:
10) Rizeq MN, et al. Incidence of myocarditis in peripartum cardiomyopathy. Am J Cardiol. 1994; 74:
11) Melvin K, et al. Peripartum cardiomyopathy due to myocarditis. N Engl J Med. 1982; 307 (12):
12) Sliwa K et al. Peripartum Cardiomyopathy: analysis of clinical outcome, LV function, plasma levels of cytokines and
Fas/Apo-1. J Am Coll Cardiol. 2000; 35 (3):
13) van Hoeven KH, et al. Peripartum versus idiopathic cardiomyopathy in young women – a comparison of clinical,
pathological and prognostic factors. Int J Cardiol 1993; 40 (1): 57-65

10. Peripartum Cardiomyopathy: Pathophysiology
Etiology (Plausible etiologic mechanisms):
- Abnormal immune response to pregnancy (chimerism)
> Fetal micro-chimerism (harboring) of fetal cells in maternal circulation14
> Natural immuno-suppression lost after delivery & if the fetal cell 5,6,14,15,16
happen to be on the cardiac tissues  pathologic autoimmune response  PPCM
- Maladaptive response to hemodynamic stress of pregnancy
> inc bld vol, inc CO, inc preload, dec afterload  brief and reversible LV hypertrophy to meet the demands of pregnancy
> ”transient LV dysfunction” during the 3rd trimester and early postpartum resolves shortly after birth16
> There is an exaggerated decrease in LV function when these hemodynamic changes occur5
5) Pearson G et al. National Heart, Lung and Blood Institute and Office of Rare Diseases (National Institute of Health)
Workshop Recommendations and review. JAMA. 2000; 283 (9):
14) Ansari AA et al. Autoimmune mechanism as basis for human peripartum cardiomyopathy.
Clin Rev Allergy Immunol. 2002; 23:
15) Hilfiker-Kleiner D, et al. Peripatum cardiomyopathy: recent insight in its pathophysiology. Trends Cardiovasc Med. 2008; 18 (5):
16) Ntusi NB, et al. Aetiology and risk factors of peripartum cardiomyopathy: a systematic review. Int J Cardiol. 2009; 131 (2):

11. Peripartum Cardiomyopathy: Pathophysiology
Etiology (Plausible etiologic mechanisms):
- Others: Prolactin
> Increased mammary gland secretion
> new proposed mechanism: excessive prolactin production
> inc Prolactin associated with:17
- Increased blood volume
- Decreased BP
- Decreased angiotensin responsiveness
- Decreased water, serum Na & K levels
- Increased erythropoietin = inc Hct
> Oxidative stress  enhanced D activity and inc prolactin cleavage in acute peripartum cardiomyopathy17
> Correlation bet pro-BNP, prolactin, oxidized LDL and interferon-Y18
17) Hilfiker-Kleiner D et al. A cathepsin D-cleaved 16kDa form of prolactin mediates peripartum cardiomayopathy.
Cell. 2007; 128 (3):
18) Forster O, et al. Reversal of IFN-gamma, oxLDL, and prolactin serum levels correlate with clinical improvement
in patients with peripartum cardiomyopathy. Eur J Heart Fail. 2008; 10:

12. Peripartum Cardiomyopathy: History & PE
Clinical Manifestations:5, 19, 20, 21
- dyspnea, SOB, dizziness, EF, orthopnea
chest pain, palpitations, cough
- BP (left lateral recumbent)
- Neck Heart
> NVE > Soft S1, S3, S4, m  changes in m
- Lungs Extremities
> Rales (bibasal) > bipedal edema
- Abdomen
> Hepatomegaly, hepato-jugular reflux
- Arrhythmia i.e. AF
- Embolic events due to dysfunctional dilated LV
5) Pearson G et al. National Heart, Lung and Blood Institute and Office of Rare Diseases (National Institute of Health)
Workshop Recommendations and review. JAMA. 2000; 283 (9):
19) Ro A et al. Peripartum cardiomyopathy. Cardiac Rev 2006; 14 (1): 35-42
20) Ramaraj R et al. Peripartum cardiomyopathy: causes, diagnosis and treatment. Clev Clin J Med. 2009; 76 (5):
21) Williams J, et al. Critical Care in Obstetrics: pregnancy-specific conditions. Best Prac Res Clin Obstet Gynaecol. 2008; 22 (5):

13. Peripartum Cardiomyopathy: Diagnosis
Evaluation: 8, 20
- Blood: CBC, electrolytes, BUN, crea, SGPT, SGOT, cardiac enzymes, BNP (pro-BNP) + urinalysis
- CXR: pulmonary edema, pneumonia
- 12L ECG
> 5-20’ L axis deviation, transient NSSTTWCs, LVH
- Echocardiogram  serial evaluation
> assess cardiac function, structural integrity
> chamber dimensions
> valvular function
> Wall motion abnormalities  global hypokinesia
- Others: CBG, thyroid function test, ultrasound, CT scan, MRI
- Diagnostic criteria
8) Johnson-Coyle L, et al. Peripartum cardiomyopathy: Review and Practice Guidelines.
Am J Critical Care 2012; 21 (2): 89-98
20) Ramaraj R et al. Peripartum cardiomyopathy: causes, diagnosis and treatment. Clev Clin J Med. 2009; 76 (5):

14. Peripartum Cardiomyopathy: Diagnosis
Evaluation: 22
- Diagnostic Criteria:
> Heart failure developing in the last month of pregnancy or within 5 months of delivery
> no identifiable cause of heart failure
> no recognizable heart disease before the last month of pregnancy
> Echo parameters:
- EF < 45% or
- FS <30% + LVEDD > 2.7 cm/m2
22) Hibbard JU, et al. A modified definition for peripartum cardiomyopathy and prognosis based on echocardiography.
Obstet Gynecol 1999; 94:

15. Peripartum Cardiomyopathy: Treatment
Peripartum Care: 1
- joint Obstetric and Cardiac care; perinat/neonat
- consider urgent termination of pregnancy in refractory HF
- vaginal delivery preferred, C/S as obstetrical indication
- lumbar epidural analgesia
- LL recumbent during labor, avoid to “push,” assisted by forceps delivery
- systemic arterial pressure monitoring, fetal monitoring, Swan is rarely needed
1) ESC Guidelines on the management of cardiovascular diseases during pregnancy.
European Heart Journal (2011) 32, 3147–3197

16. Peripartum Cardiomyopathy: Treatment
Peripartum Care: 5, 21, 23
HF treatment as per guidelines
similar to other forms of heart failure
careful attention to a) fetal safety
b) drug excretion
c) drug metabolism
- Goals:
> Improve hemodynamic status
> Minimize signs & symptoms
> Optimize long term outcome
- Focus:
> reducing preload and afterload
> increasing/improving cardiac inotropy
5) Pearson G et al. National Heart, Lung and Blood Institute and Office of Rare Diseases (National Institute of Health)
Workshop Recommendations and review. JAMA. 2000; 283 (9):
21) Williams J, et al. Critical Care in Obstetrics: pregnancy-specific conditions. Best Prac Res Clin Obstet Gynaecol. 2008; 22 (5):
23) Tidswell M, et al. Peripartum cardiomyopathy. Critical Care Clin. 2004; 20:

17. Peripartum Cardiomyopathy: Treatment
Peripartum Care: 8
Hospitalization due to a) hypotension
b) worsening HF
c) altered mental status
d) inc work of breathing (pul edema)
- Management:
> vasodilators/unloaders: ACE-I/ARB (CI), nitrates, hydralazine,
diuretics
> fluid restriction; Na restriction
> CBR
8) Johnson-Coyle L, et al. Peripartum cardiomyopathy: Review and Practice Guidelines.
Am J Critical Care 2012; 21 (2): 89-98

18. Peripartum Cardiomyopathy: Treatment
Postpartum Care: 8
- Focus:
> reducing preload and afterload
> increasing/improving cardiac inotropy
- Medications:
1) ACE-I/ARB – capto, enal, cande, valsar, los, telmi
2) digoxin
3) diuretics – furosemide/spironolactone
4) BB – metoprolol, carvedilol
5) Inotropes – dobutamine, dopamine, milrrinone, levosimendan
6) anticoagulation – LMWH/UFH/warfarin/ASA* (warcef)24
7) Others:
- Cardiac support options a) intra-aortic balloon pump
b) LV assist device
c) cardiac transplantation = 4% of PPCM
8) Johnson-Coyle L, et al. Peripartum cardiomyopathy: Review and Practice Guidelines.
Am J Critical Care 2012; 21 (2): 89-98
24) Homma S et al. Warfarin and aspirin in patients with heart failure and sinus rhythm.
N Engl J Med. 2012; 366 (20):

19. Peripartum Cardiomyopathy: WARCEF STUDY
- Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhtyhm Homma S et al. N Engl J Med 2012; 366(20):
- WARCEF  Warfarin vs Aspirin in Reduced Cardiac Ejection Fraction
- Hypothesis: Is warfarin superior to aspirin alone for patients with heart failure who are in sinus rhythm?
- P : 2,305 HF patients < 35% with sinus rhythm
I : Warfarin (1,163) vs ASA 325mg (1,142)
O : First event of composite endpoint of ischemic stroke,
intracerebral haemorrhage and death
M : double blind randomized clinical trial,
W: INR=2-3, A: 325mg OD
24) Homma S et al. Warfarin and aspirin in patients with heart failure and sinus rhythm.
N Engl J Med. 2012; 366 (20):

20. Peripartum Cardiomyopathy: WARCEF STUDY
- P : 2,305 HF patients < 35% with sinus rhythm
I : Warfarin (1,163) vs ASA 325mg (1,142)
O : First event of composite endpoint of ischemic stroke,
intracerebral haemorrhage and death
M : double blind randomized clinical trial, W: INR=2-3, A: 325mg OD
- Results:
> Primary Outcome: HR= 0.93 ( ) NS
> Ischemic Stroke (W): HR= 0.52 ( ) p=0.005
> Major Haemorrhage (W): HR=2.1 ( ) p<0.001
- Conclusion:
> Patients w/ HF + sinus rhythm warfarin reduces risk of ischemic
stroke but at a cost of increased major haemorrhage
> no significant difference between ASA and warfarin in the
composite endpoint of death, ischemic stroke and IC bleed or HF
hospitalization
> No compelling reason to use warfarin over aspirin for patients with
systolic heart failure and sinus rhythm
24) Homma S et al. Warfarin and aspirin in patients with heart failure and sinus rhythm.
N Engl J Med. 2012; 366 (20):

21. Peripartum Cardiomyopathy: Treatment
Postpartum Care:
- Medications:20
7) Others: in refractory heart failure, limited data
a) pentoxifylline – improve outcomes, LV function/ S&S
b) IV immonoglobulin – improved EF, reduced levels of
inflammatory cytokines
c) immunosuppressive therapy – no proven role but could
be tried in proven viral myocarditis
d) Bromocriptine*25
e) others: monoclonal antibodies, interferon, therapeutic
aphoresis, cardiomyoplasty
- Cardiac support options a) intra-aortic balloon pump
b) LV assist device
c) cardiac transplantation = 4% of PPCM
20) Ramaraj R et al. Peripartum cardiomyopathy: causes, diagnosis and treatment. Clev Clin J Med. 2009; 76 (5):
25) Sliwa K et al. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy:
a proof of concept pilot study. Circulation. 2010; 121:

22. Peripartum Cardiomyopathy: Bromocriptine Study
- Evaluation of Bromocriptine in the Treatment of Acute Severe Peripartum Cardiomyopathy (A Proof of Concept Pilot Study)
Sliwa K et al. Circulation. 2010; 121:
- Hypothesis: Prolactin (mainly 16-Kda angiostatic and proapoptotic form) initiates and rives PPCM and that early pharmacologic blockade of prolactin with bromocritptine may improve the patients’ condition before irreversible cell damage sets in, looked into as HF therapy to improve LVEF, functional class and survival in women with acute severe PPCM.
- P : 20 PPCM patients < 35% with SBP >95 < 160 /or DBP < 105
I : PPCM-Std (10) vs PPCM-Br (10)
O : composite endpoint of death, NYHA Class 3 /4,
LVEF <35% at 6months
M : prospective randomized open-label clinical trial,
PPCM-Std: Enalapril, carvedilol, furosemide, warfarin
PPCM-Br: Std + 2.5mg BID X 2wks, 2.5mg OD X 6wks
25) Sliwa K et al. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy:
a proof of concept pilot study. Circulation. 2010; 121:

23. Peripartum Cardiomyopathy: Bromocriptine Study
- P : 20 PPCM patients < 35% with SBP>95 < 160 /or DBP<105
I : PPCM-Std (10) vs PPCM-Br (10)
O : composite endpoint of death, NYHA class 3 /4,
LVEF <35% at 6months
M : prospective randomized open-label clinical trial,
PPCM-Std: Enalapril, carvedilol, furosemide, warfarin
PPC-Br: Std + 2.5mg BID X 2Wks, 2.5 OD X 6Wks
- Results:
> Similar in baseline characteristics: BP, Labs, LVED/LVESD, LVEF
> Changes in NT-proBNP, 16kDa prolactin & cathepsin D = NS
> Changes in S or D BP and LVEDD or LVESD = NS
25) Sliwa K et al. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy:
a proof of concept pilot study. Circulation. 2010; 121:

24. Peripartum Cardiomyopathy: Bromocriptine Study
- Results:
> Recovery of EF: 31% better for PPCM-BR (2758%);
PPCM-Std (27%36%), p=0.012
> Primary Outcome: PPCM-Br patients better outcome, P=0.006
25) Sliwa K et al. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy:
a proof of concept pilot study. Circulation. 2010; 121:

25. Peripartum Cardiomyopathy: Bromocriptine Study
- Results: 25
> Recovery of EF: 31% better for PPCM-BR (2758%);
PPCM-Std (27%36%), p=0.012
> Primary Outcome: PPCM-Br patients better outcome, P=0.006
- Conclusion:
> Addition of bromocriptine to standard HF therapy appears to
improve LVEF, functional class and survival in women with severe
acute PPCM w/ no obvious detriment to their children at 6 mos of study.
> beneficial effects said to result from eliminating detrimental effects of
16 kDa prolactin form
> “off target” effects on hemodynamics26, 27
 increase in BP, vascular resistance, plasma norepinephrine levels
 increase SVI, decrease LV filling pressure
> Caution: reports of stroke, seizure, coronary vartery thrombosis and
coronary vasospasm in normal women
25) Sliwa K et al. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy:
a proof of concept pilot study. Circulation. 2010; 121:
26) Francis GS, et al. The effects of bromocriptine in patients with congestion heart failure.
Am Heart J. 1983; 106 (pt1):
27) Goldberg LI, et al. The role of dopamine receptors in the treatment of congestive heart failure.
J Cardiovasc Pharmacol. 1989; 14 (suppl 5): s19-s27

26. Peripartum Cardiomyopathy: Prognosis
- Treatment duration: continued until recovery of LV function,
6-12 months or lifetime
- Usually return to normal heart size within 6 months
% recover baseline LV function within 6 months16, 28
- Prognosis is positively related to recovery of LV function16
- failure of LV size to return to N is associated w/ inc M & M5
- 94% survival rate in 5 years29; Mortality vary: 0-9% 15%4
- Recurrence risk in subsequent pregnancies = 30-50%
4) Fett JD et al. Five year prospective study of the incidence and prognosis of peripartum cardiomyopathy at a single institution.
Mayo Clin Proc 2005; 80 (12):
5) Pearson G et al. National Heart, Lung and Blood Institute and Office of Rare Diseases (National Institute of Health)
Workshop Recommendations and review. JAMA. 2000; 283 (9):
16) Ntusi NB, et al. Aetiology and risk factors of peripartum cardiomyopathy: a systematic review. Int J Cardiol. 2009; 131 (2):
28) Abboud J, et al. Peripartum cardiomyopathy: a comprehensive review. Int J Cardiol. 2007; 118 (3):
29) Felker GM, et al. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy.
N Engl J Med. 2000; 342:

27. Peripartum Cardiomyopathy: Prognosis
- Predictors for normalization:30, 31
a) LVEDD < 55mm
b) LVEF > 27%
- Predictors for persistent LV dysfunction:30, 31, 32
a) Trop T (measured 2 wks after onset) = inversely correlated
with LV function at 6 months: > 0.04ng/ml (Sn=55%, Sp=91%)
b) FS < 20%
c) LVEDD > 56 – 60 mm
- EF is the strongest predictor of outcome12
12) Sliwa K et al. Peripartum Cardiomyopathy: analysis of clinical outcome, LV function, plasma levels of cytokines and
Fas/Apo-1. J Am Coll Cardiol. 2000; 35 (3):
30) Dorbala S et al. Risk stratification of women with peripatum cardiomyopathy at initial presentation:
a dobutamine stress echocardiography study. J Am Soc Echocardiogr 2005; 18: 45-48
31) Duran N, et al. Predictors of prognosis in patients with peripartum cardiomyopathy. Int J Gynaecol Obstet 2008; 101:
32) Hu CL, etal. Troponin T measurement can predict persistent left ventricular dysfunction in peripartum cardiomyopathy. Heart 2007; 93:

28. Peripartum Cardiomyopathy: Prognosis
- Counselling: (recommendation for subsequent pregnancy)
> do DBS to measure maximal inotropic contractile reserve
correlated with subsequent recovery of LV function
 Recommendations:30
a) if LV function recovered fully, subsequent pregnancy not CI but
should be warned of recurrence
b) if partial LV function recovered, perform the DBS:30
- N response (appropriate augmentation)  pregnancy not CI
but warned
- AbN response, risk is moderate, subsequent pregnancy CI
c) if LV function not recovered, subsequent pregnancy CI
30) Dorbala S et al. Risk stratification of women with peripatum cardiomyopathy at initial presentation:
a dobutamine stress echocardiography study. J Am Soc Echocardiogr 2005; 18: 45-48

29. Peripartum Cardiomyopathy: Summary
- Peripartaum cardiomyopathy is distinctly defined albeit a diagnosis mostly by exclusion with its criteria
- Plausible etiologic mechanisms make it difficult for
targeted treatment regimen
- Treatment is based on HF guidelines,
w/ the goal of improving hemodynamic status
focused on reducing preload / afterload and
increasing cardiac inotropy with careful attention to
fetal safety, drug metabolism and excretion.

30. Peripartum Cardiomyopathy: Summary
- Provide standard HF care, ASA recommended and
bromocriptine is a new option for intractable HF
- Mortality varies up 15% but overall prognosis is
good with more than 90% survival rate in 5 years
- Predictors for prognosis should be used when counselling
patients regarding subsequent pregnancy who are at high
risk for recurrence

31. Thank you for your attention!
“Knowing is not enough;
We must apply.
Willing is not enough;
We must do.”
Johan Wolfgang von Goethe 31