RESUMO
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