Loop diuretics can cause clinical natriuretic failure: a prescription for volume expansion.

Ultrafiltration enhances volume removal and weight reduction vs diuretics. However, their differential impact on total body sodium, potassium, and magnesium has not been described. Fifteen patients with congestion despite diuretic therapy had urine electrolytes measured after a diuretic dose. Ultrafiltration was initiated and ultrafiltrate electrolytes were measured. The urine sodium after diuretics (60+/-47 mmol/L) was less than in the ultrafiltrate (134+/-8.0 mmol/L) (P=.000025). The urine potassium level after diuretics (41+/-23 mmol/L) was greater than in the ultrafiltrate (3.7+/-0.6 mmol/L) (P=.000017). The urine magnesium level after diuretics (5.2+/-3.1 mg/dL) was greater than in the ultrafiltrate (2.9+/-0.7 mg/dL) (P=.017). In acute decompensated heart failure patients with congestion despite diuretic therapy, diuretics are poor natriuretics and cause significant potassium and magnesium loss. Ultrafiltration extracts more sodium while sparing potassium and magnesium. The sustained clinical benefits of ultrafiltration compared with diuretics may be partly related to their disparate effects on total body sodium, potassium, and magnesium, in addition to their differential efficacy of volume removal.

Case report: Concurrent congenital complete atrioventricular block, Meckel's diverticulum and cerebral palsy in a 19-year-old male.

A case report is described of a patient with cerebral palsy and Meckel's diverticulum presenting with congenital atrioventricular (AV) block. There is limited information of congenital heart block in adults, because most literature has been devoted to congenital heart block in childhood. This unique case is discussed with other patient groups' with congenital AV block. Long-term follow-up of congenital heart block is reviewed together with the concept of prophylactic pacemaker placement in symptom-free adults.

A comparison of myocardial perfusion and rejection in cardiac transplant patients.

INTRODUCTION: Although histological evaluation of the cardiac tissue is the current gold standard for evaluation of rejection, we hypothesized that cardiac perfusion MRI is a safe non-invasive method that correlates tissue blood flow changes with biopsy proven rejection in the cardiac transplant patient. MATERIALS AND METHODS: In a retrospective study from 1984-2001, 83 patients underwent 135 MR Gd-DTPA imaging studies. In 8 patients (9%), biopsies graded 2 or higher (by ISHLT criteria) provided evidence of rejection. Patients were age and sex matched to 11 non-rejected controls for imaging analysis. Time-signal intensity curves generated for a mid-ventricle LV short axis slice during rest and adenosine stress allowed determination of myocardial blood flow (MBF, ml/min/gm). ROC curve analysis by SPSS allowed estimation of sensitivity and specificity. RESULTS: At rest, there was no difference in MBF between patients with prior rejection vs. those without (1.18 +/- 0.26 vs. 1.16 +/- 0.29). At stress there was a decrease in MBF for patients with prior rejection episodes (3.27 +/- 0.74) compared to no rejection (3.60 +/- 0.72), P = 0.067). The area under the ROC curve was 0.82, with specificity and sensitivity of 75% and 81%, respectively. CONCLUSION: This study suggests that perfusion MR imaging can be used in assessing the cardiac transplant patient for rejection related microvascular changes. The high specificity and sensitivity recorded from the ROC curve illustrates the potential utility of this diagnostic test for future studies.

Large volume ultrafiltration for acute decompensated heart failure using standard peripheral intravenous catheters.

BACKGROUND: Ultrafiltration for decompensated heart failure has recently generated significant clinical interest with the development of a portable machine that does not require an intensive care or dialysis unit. This case series was designed to demonstrate the feasibility and effectiveness of performing large volume ultrafiltration via peripherally inserted standard intravenous (IV) catheters in patients with acute decompensated heart failure. METHODS AND RESULTS: Nine hospitalized patients with decompensated heart failure underwent peripheral ultrafiltration (PUF) therapy with peripheral IV catheters. The mean length of time of PUF therapy was 33.3 +/- 20.0 hours with a mean volume removed of 7.0 +/- 4.9 L. All patients experienced a statistically significant mean weight loss of 6.2 +/- 5.0 kg, P = .01. There was no statistically significant change in renal function. CONCLUSION: We report the first successful implementation of ultrafiltration via standard peripheral IV catheters to remove a large volume of fluid over an extended period of time reliably in a small group of patients. The ability to use PUF therapy via peripheral IV catheters will potentially allow this therapy to be implemented more easily in a variety of care settings to treat patients with resistant heart failure.