Study of slow ultrafilteration as a therapeutic modality for chronic refractory congestive heart failure

Refractory heart failure usually represents the end stage of congestive heart failure in which hypotension and oliguria, lead to progressive generalized edema. The purpose of this study was to assess the efficacy of extracorporeal ultrafilteration [ECUF] as a modality for treatment of patients with refractory congestive heart failure who failed to respond to conventional anti failure measures. The study was carried out at a period for about six months and it included 40 patients, 18 men [45%] and 22 women [55%], they were selected from patients admitted to the intensive care of Internal Medicine Department and cardiology Department of Tanta University Hospital. Selection criteria were NYHA class III and IV heart failure, resting left ventricular ejection fraction [LVEF] <35, normal or mild elevated serum creatinine [patients with chronic renal failure were excluded from the study], lack of satisfactory response to conventional therapeutic regimen. All patients were subjected To ECUF ranged from 3 sessions in 12 patients and 4 sessions in 28 patients [mean 3.7 session/ptn] and between [4-6 hour/session]. It was initated at a rate of 0.5L/h to be readjusted subsequently according to the hemodynamic parameters available. Average amount of ultrafilterate/session ranged from 2.5-3 liters [mean2.6 +/- 0.4]. Both number and repition frequency were decided empirically on the basis of evolution of symptoms and response to drugs. All patients were subjected to the following assessment before and after ECUF: Daily morning checking of body weight [kg], hematocrit value [HTC%], urin output [ml/24h], serum electrolytes [Na[+], K[+]], blood urea and serum creatinine, hemodynamic monitoring including [heart rate, blood pressure and CVP], chest x-ray P-A view for measurment of CTR, E.C.G and transthoracic echocardiography for evaluation of cardiac function. Our results showed that there was significant increase of diuresis from [0.3410.14 to 2.0 +/- 0.7L/day] [p<0.001], significant reduction of mean H.R [120+5.0 to 98 +/- 11.0 beat/min] [p<0.001], significant CVP reduction [28.5 +/- 2.o to 15.5 +/- 7.0 cm water] [p<0.001], decrease of intravenous volume as assessed by significant increase of HCT value from [33.8 +/- 2.3% to 37.6 +/- 2.0%] [p<0.001] after ECUF, significant decrease of S. urea from [105.7 +/- 55.2 to 91.3 +/- 63.o4 mmol/L] and S. creatinine from [1.9 +/- 0.6 to 1.5 +/- 0.9 mmol/L] after ECUF. ECHO repeated after ECUF revealed highly significant reduction in the mean LVEDD from [7.0 +/- 0.2 cm to 6.4 +/- 0.6 cm] [p<0.001], reduction of LVESD from [6.5 +/- 0.4 cm to 5.5 +/- 0.8 cm] [p<0.001], reduction in mean LA dimension from [5.3 +/- 0.3 cm to 4.8 +/- 0.6 cm] [p<0.001], reduction of RV dimension from [4.7 +/- 0.4 cm to 4.0 +/- 0.8 cm] [p<0.001], significant increase of LVEF from [23.8 +/- 4.1 to 31.2 +/- 8.2] [p<0.001]: ECUF offers a reasonable effective and relatively safe method in the treatment of refractory heart failure. The relative ease of the procedure and low incidence of complications denote that this technique is a useful one in selected cases of heart failure, refractory to the conventional therapy with oliguria and fluid overload

Circulatory response to fluid overioad removal and sustained hemodynamic efficacy of slow ultrafiltration in refractory congestive heart failure

To determine to what extent patients with chronic refractory congestive heart failure [rCHF] benefit from slow Ultrafiltration. Prospective, observational study of chronic refractory congestive H.F. Effectiveness data from several sources, including observational studies, published systemic reviews, The New York Heart Association [NYHA] classification of Heart failure and expert opinion. New York Heart Association [NYHA] class III and IV, resting left ventricular ejection fraction < 35%, Dilated cardiomyopathy, Ischemic cardiomyopathy and normal or mild elevated serum creatinine < 3 mg/dl. Forty Patients, eighteen men [45%] and twenty two women [55%], their ages ranged from 32 to 63 years [mean 47 +/- 9 years] with refractory CHF, with NYHA functional class IV [n = 32] represent 80% and class III [n = 8] represent 20% of patients, were selected from intensive care units of Internal Medicine and Cardiology Departments of Tanta university Hospital. Exclusion criteria were patients with advanced valvular heart diseases and patients with chronic renal failure - All patients were subjected to the following assessments : Daily morning B.W, HTC%, Serum electrolytes [Na[+], K[+], Ca[+2]], Blood urea and S. creatinine, Urine output [ml/24h.] and homodynamic monitoring including H.R, Systemic BL Pr and CVP [by double luminal catheter], Chest x-ray P.A view, examination for interstitial and/or clear cut alveolar pulmonary edema before and after ECUF [Extra corporeal ultrafiltration] ECG and Trans-thoracic Echocardiography [M-mode, two dimensional and Doppler Echocardiography]. Controlled ultrafiltration between 0.5-1 L/h., was initiated at a rate of 0.5 L/h to be readjusted subsequently according to the hemodynamic parameters available. All patients were subjected to ECUF treatment ranged from 3 sessions in 12 patients and 4 sessions in 28 patients [mean 3.7 session/ptn], and about 4-6 h/session. Average amount of ultrafiltrate /session ranged from 2-3.5 liters [mean 2.6 +/- 0.4 liter] over duration of 15 days hospital admission. Both number and repetition frequency were decided empirically on the basis of evolution of symptoms and response to drugs. ECUF was discontinued when it was considered clinically that the maximum benefit has been obtained. Highly significant diuresis from [0.34 +/- 0.14 to 2.0 +/- 0.7 L/day] [P < 0.001], reduction in the mean H.R[120 +/- 5.0 to 98 +/- 11.0 beat/min] [P < 0.001], CVP reduction [28.5 +/- 2.0 to 15.5 +/- 7.0 cm water] [P < 0.001], Intra-venous volume as assessed by HCT value [33.8 +/- 2.3% to 37.6 +/- 2.0%], [P < 0.001] before and after ECUF. ECHO was repeated after ECUF revealed highly significant reduction in the mean LVEDD from 7.0 +/- 0.2 cm before to 6.4 +/- 0.6 cm after ECUF [P < 0.001], LVESDfrom 6.5 +/- 0.4 cm before to 5.5 +/- 0.8 cm after ECUF [P< 0.001]. LVEF was 23.8 +/- 4.1% before and increased to 31.2 +/- 8.2% after ECUF [P < 0.001], highly significant reduction in the mean L A dimensions from 5.3 +/- 0.3 cm before to 4.8 +/- 0.6 cm after ECUF [P < 0.001], RV dimensions from 4.7 +/- 0.4 cm before to 4.0 +/- 0.8 cm after ECUF [P < 0.001]. Significant changes in S.urea from 105.7 +/- 55.2 mmol /L to 91.3 +/- 63.04 mmol /L] [P < 0.047], S. creatinine from [1.9 +/- 0.6 to 1.5 +/- 0.9 mmol/L] [P < 0.017] before and after ECUF. ECUF offers a reasonably effective and relatively safe method in the management of r CHF. The relative ease of the procedure and low incidence of complications denote that this technique is an extremely useful one in selected cases of H.F, refractory to the conventional therapy with oliguria and fluid overload