Dilated uremic cardiomyopathy in a dialysis patient cured by persistent ultrafiltration.

A patient is presented who after 2 years of hemodialysis showed all of the features of congestive cardiomyopathy to a very severe degree: dilation of all cardiac compartments, increased left ventricular mass, low ejection fraction, diastolic disturbances, third- to fourth-degree mitral and tricuspid regurgitation, ascites, and low blood pressure. All of these abnormalities gradually but completely disappeared during 5 months of persistent ultrafiltration during or between dialysis sessions. It was concluded that chronic fluid overload was a major factor in the cardiac disease of this patient. Unrecognized hidden fluid overload has long been known (but also neglected), and its prevention deserves top priority in chronic dialysis patients.

'Paradoxical' rise in blood pressure during ultrafiltration in dialysis patients.

In some hypertensive haemodialysis (HD) patients, blood pressure rises further during ultrafiltration (UF). We investigated seven such patients, who were not responsive to hypotensive drugs, including converting enzyme inhibitors. All had marked cardiac dilatation, but most were non-oedematous. They were treated with repeated intense UF while monitoring cardiac function by echocardiography. After a variable time period they all became (near) normotensive without medication. Mean systolic and diastolic blood pressure decreased by 46 +/- 18 and 22 +/- 9 mmHg respectively while bodyweight decreased by a mean of 6.7 +/- 3.0 kg. Plasma volume decreased by 22%, and mean albumin increased from 3.9 +/- 0.3 to 4.2 +/- 0.3 g/dl. Cardiothoracic index decreased from a 0.56 +/- 0.02 to 0.45 +/- 0.03. Mitral and tricuspid insufficiency was present in four patients and improved or disappeared in all of them. Diameters of the inferior vena cava, left atrium, and end systolic and diastolic left ventricle markedly decreased in all patients. Ejection fraction increased, but remained subnormal in some patients, while cardiac output increased in five and decreased in two patients. We conclude that paradoxical blood pressure rise with UF usually occurs in the presence overhydration and cardiac dilatation and should be treated by intensified UF. The explanation of this phenomenon remains speculative.

Mitral balloon valvuloplasty with transesophageal echocardiography without using fluoroscopy.

Balloon mitral valvuloplasty with Inoue technique was performed in two group of patients. In group I (n = 40) valvuloplasty was performed under fluoroscopy without using echocardiography, whereas in group II (n = 13) valvuloplasty was performed under the guidance of transesophageal echocardiography alone, without using fluoroscopy. Patients in two groups were comparable with regard to clinical variables and hemodynamic parameters. Two female patients in group II were pregnant. Transmitral pressure gradient decrease did not differ significantly between two groups (pressure gradient: 17 +/- 5 to 4 +/- 1 in group I and 15 +/- 4 to 3 +/- 1 mm Hg in group II). Mitral valvular area increase was also not different in two groups (1.09 +/- 0.2 cm2 to 2.3 +/- 0.5 cm2 in group I and 0.9 +/- 0.2 to 2 +/- 0.3 cm2 in group II). In 14 cases from group 1 and 2 cases from group II mitral regurgitation increased after valvuloplasty (p < .05). Left atrial perforation occurred in one patient from group 1 and 2 patients from group II. In conclusion, mitral balloon valvuloplasty under transesophageal echocardiographic guidance alone is a safe and effective procedure in the treatment of mitral stenosis.