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Treatment of end-stage congestive heart failure by extracorporeal ultrafiltration
February
Treatment of End-StageCongestive Heart Failure by Extracorporeal Ultrafiltration LUIGI DONATO, MD ANDREA BIAGINI, MD CARLO CONTINI, MD ANTONIO L’ABBATE, MD MICHELE EMDIN, MD MARCELLO PIACENTI, MD ROBERTO PALLA, MD
A
lthough progress in the field of inotropic, diuretic and vasodilator drugs has markedly improved prognosis in patients with acute congestive heart failure (CHF),l chronic CHF is a growing problem because of its increased incidence2 as a result of increased survival from acute episodes and because patients may become nonresponsive to medical treatment. Extracorporeal ultrafiltration [ECUF) makes possible rapid removal, with fewer adverse effects than hemodialysis and peritoneal dialysis, of fluid, electrolytes and other solutes.3 Therefore, ECUF could be used in patients with refractory CHF as a means of temporarily relieving intolerable or intractable respiratory distress and refractory edema or as an emergency measure to reduce cardiac preload. Furthermore, ECUF could eventually correct the electrolyte alterations frequently found in these patients as a result of long-standing diuretic treatment. This report documents clinical results, both in the acute phase and in the follow-up period, in 8 patients with end-stage CHF who underwent ECUF. All 8 patients (7 men, 1 woman) were in New York Heart Association (NYHA) functional class IV. In 3, aged 36,50 and 65 years, CHF resulted from idiopathic dilated cardiomiopathy; these patients had been in severe CHF for 6 months, 3 years and 10 months, respectively, and 2 of them also had iatrogenic hyperthyroidism from prolonged amiodarone treatment. In 5 patients, aged 53, 71, 72, 72 and 73 years, CHF had lasted 4 to 10 years as a result of coronary artery disease, with repeated myocardial infarctions over the past 4 to 16 years. All had been treated with inotropic, diuretic and vasodilator agents in different combinations and all showed a diminishing response to drugs despite increasing dosages, ingravescent oligo-anuria and gain in body weight related to anasarcatic edemas, extreme heart enlargement and pulmonary congestion. Life expectancy was estimated to be less than 3 months in all cases. From the CNR Institute of Clinical Physiology Pisa and Patologia Medica and Hemodialysis Unit, University of Pisa. Pisa, Italy. This study was supported in part by a grant from the CNR Special Project of Biomedical and Clinical Engineering. Manuscript received June 5,1988; revised manuscript received August l&1986, accepted August 13,1986.
1, 1987
THE
AMERICAN
JOURNAL
OF CARDIOLOGY
Volume
59
379
ECUF was performed, filtering venous blood collected through a catheter positioned percutaneously in the inferior vena cava, by a high-permeability polyacrylonitrile membrane (dialyser surface 1.03 m2; cutoff point MW <20,000); venous return was accomplished by a second catheter in an antecubital vein. Treatment ranged from 1 session only in 1 case to 5 sessions (mean 3.4 sessions/patient) over a maximum of 9 days. Both number and repetition frequency were decided empirically on the basis of evolution of symptoms and response to drugs. Body weight loss ranged from 1.7 to 5.7 kg/session (mean 2.8), with a total loss of 10.9 to 14.7 kg [mean 11.5 kg/patient) in the subjects who had 2 to 5 sessions and of 3.5 kg in the patient who had 1 session only. During ECUF, all drug treatment was withdrawn in 5 cases; in 3 patients medication was continued, but in small doses. Clinical improvement was usually dramatic, particularly in regard to respiratory distress and refractory edemas. Urine output remained low during ECUF, but increased with resumption of treatment in moderate dosages. Body weight loss usually continued after ECUF, with an increase in urine output (at discharge mean total body weight loss was 13.4 kg [range 8 to 24). Pulmonary congestion was graded using a chest x-ray scoring approach4: score ranges at discharge from hospital (9.6 f 2.1) were significantly lower than those before ECUF (28.2 f 18.11, whereas changes in heart size were not significant. In our first patient (age 36 years, with dilated cardiomyopathy), 2 weeks after ECUF body weight increased again and urine output decreased despite treatment, with reappearance of respiratory distress and multifocal ventricular premature complexes. The patient died 20 days later. Patient 4, also with dilated cardiomyopathy, underwent successful heart transplantation 3 weeks after ECUF and is doing well 24 months later. Six subjects were discharged from the hospital 2 to 3 weeks after ECUF, all markedly improved with moderate medical treatment. They were followed at the outpatient clinic every 2 months and were instructed to contact the hospital to repeat ECUF at any sign of clinical worsening. In patients 2 and 7, ECUF (1 session) was repeated 4 and 2.5 months later, respectively, to restore electrolyte balance without fluid removal in patient 2 and to check relapse of symptoms in patient 7, with results similar to previous results. Improvement was maintained at home with moderate treatment and all 6 subjects resumed moderate physical activity. Six of them are still alive, 4,7, 9,9,10 and 24 months after ECUF. Quality of life was uniformly reported as markedly improved. One patient [age 72 years) died 1 year later from cerebrovascular stroke. We have no explanation for the pathophysiologic mechanisms of the observed effects. Our initial hypothesis that ECUF could simply replace excretion to maintain fluid balance in patients no longer responding to drugs does not explain the duration of improvement after ECUF. In these patients, a resetting of the hemodynamic and fluid balance mechanisms appears to have taken place; consequently, we believe that a
380
BRIEF REPORTS
functional disturbance was associated with structural heart damage in the inducement of intractable CHF. The factors responsible for it were removed by ultrafiltration, resulting in resetting of the mechanism on a more favorable cycle. These data agree with those reported by Page et a1,5 who suggested that in patients with terminal CHF refractory to medical treatment, ECUF may prolong and improve life. This could be particularly valuable in patients in whom heart transplantation is not immediately accessible both to improve the clinical standard of the patient before sur-
PercutaneousBalloonValvuloplasty of Mitral StenosisAided by CardiacUltrasound
gery and to prolong life expectancy while waiting for a heart donor. 1. Opie LH. Principles of theropy for congestive 1984;4:suppl A:199-208. 2. Gorlin R. Incidence, etiology and prognosis Rev Resp 1983;4:765-770.
heart failure.
Eur Heart
1
of heart failure. Cordiovasc
3. Ing TS. Chen WT, Daugirdas JI, Kwaan HC, Hans JE.Isolated ultrafiltration and new techniques of ultrafiltration during dialysis. Kidney Int 1980;18:577582. 4. Pistolesi M, Giuntini C. Assessment of extravascular lung water. Radio1 Clin North Am 1978;16:551-574,
5. Page E, Machecourt J, Dechelette E. Wolf JE, Bourlard P, Denis B. Traitment des insuffisances tion corporelle. Arch
cardiaques Ma1 Coeur
ovec oedemes r6froctoires 1984:77:1040-1045.
par ultrafiltra-
A 55year-old man with rest dyspnea due to known mitral stenosis was referred for percutaneous balloon valvuloplasty. After sedation with diazepam (IO mg) and under local anesthesia with xylocaine, the right femoral vein was cannulated with a No. 8Fr, 59-cmlong MuJJins sheath and dilator (U.S.C.I.), which were advanced via an 0.038-inch guidewire to the superior vena cava, where the wire was withdrawn. A standard Brockenbrough needle was advanced to the tip of the dilator, both needle and dilator were withdrawn to the Jimbus of the fossa ovalis of the atrial septum and the
needle, followed by the dilator and sheath, were advanced into the left atrium. The needle and dilator were then removed and a balloon-tipped 7Fr endhole catheter (Edwards, Inc.) was advanced through the sheath to the left atrium, across the mitral valve, through the left ventricle, across the aortic valve and into the descending aorta. An 0.038-inch 400-cm exchange wire (Cook, Inc.) was then inserted into the balloon catheter and passed through the descending aorta into the left femoral artery, The balloon catheter was then exchanged for a No. 9Fr catheter with an 8mm diameter, 3-cm-long balloon (Mansfield Scientific), which was advanced through the exchange wire across the interatrial septum and used to dilate the atrial septostomy. The 8-mm balloon catheter was then exchanged for a 9Fr catheter with a 20-mm-diameter, 3-cm-long balloon (Mansfield). In advancing the 20-mm balloon catheter, resistance was encountered at what was believed to be the site of the atria1 septum. A mild degree of balloon inflation carried out during 2-D echocardiographic imaging at this point disclosed that the catheter had crossed the atrial septum (Fig. 1, left]. When further advancement of the balloon catheter was obviated by more resistance, echocardiography showed that the catheter could not negotiate the mitral valve orifice (Fig. I, right). Using a combination of fhoroscopic and echocardiographic imaging, continued manipulation of the catheter resulted in successful negotiation of the stenotic mitral valve orifice (Fig. 2, left), after which balloon valvuloplasty was performed (Fig. 2, right). After valvuloplasty was performed, the mitral valve gradient decreased from 25 to 11 mm Hg, cardiac output increased to 4.5 Jiters/min, and calculated mitral valve orifice area increased from 0.7 to I.2 crn2. Pulmonary arterial pressure decreased from 641 22 mm Hg (mean 38) to 50/16 mm Hg (mean 30 mm Hg). The patient tolerated the procedure without difficulty. At 3-month follow-up examination, the patient had no rest dyspnea and had exertional dyspnea only during strenuous exercise.
From the Departments of Medicine (Cardiology] and Pediatrics [Cardiology). Tufts-New England Medical Center, Boston, Massachusetts. Manuscript received September 11, 1986, accepted September 15,1986.
The atria1 septum and the stenotic mitral valve constitute 2 potential sites of resistance to advancement of the larger valvular dilation catheters. The relatively short distance and sharp bend from the fossa ovalis site
NATESA G. PANDIAN, MD JEFFREY M. ISNER, MD THOMAS J. HOUGEN, MD MARK R. DESNOYERS, MD KEVIN MclNERNEY, BS DEEB N. SALEM, MD
R
ecent report@ have established the feasibility of percutaneous balloon dilation of stenotic mitral valves. The standard transseptal technique used for this procedure was modified by Lock et al2 to include dilation with an 8-mm balloon catheter of the ostium created in the atria1 septum. Successful transseptal delivery of the larger balloons required for mitral valve dilation depends on an adequate-sized atria1 septostomy; too small a defect may interfere with advancement of the valvular dilation catheter toward the mitral orifice. The present report describes the manner in which &dimensional (2-D] echocardiography was successfully used to monitor delivery of the valvular dilation catheter across the atria1 septum and through the mitral orifice.
Treatment of End-StageCongestive Heart Failure by Extracorporeal Ultrafiltration LUIGI DONATO, MD ANDREA BIAGINI, MD CARLO CONTINI, MD ANTONIO L’ABBATE, MD MICHELE EMDIN, MD MARCELLO PIACENTI, MD ROBERTO PALLA, MD
A
lthough progress in the field of inotropic, diuretic and vasodilator drugs has markedly improved prognosis in patients with acute congestive heart failure (CHF),l chronic CHF is a growing problem because of its increased incidence2 as a result of increased survival from acute episodes and because patients may become nonresponsive to medical treatment. Extracorporeal ultrafiltration [ECUF) makes possible rapid removal, with fewer adverse effects than hemodialysis and peritoneal dialysis, of fluid, electrolytes and other solutes.3 Therefore, ECUF could be used in patients with refractory CHF as a means of temporarily relieving intolerable or intractable respiratory distress and refractory edema or as an emergency measure to reduce cardiac preload. Furthermore, ECUF could eventually correct the electrolyte alterations frequently found in these patients as a result of long-standing diuretic treatment. This report documents clinical results, both in the acute phase and in the follow-up period, in 8 patients with end-stage CHF who underwent ECUF. All 8 patients (7 men, 1 woman) were in New York Heart Association (NYHA) functional class IV. In 3, aged 36,50 and 65 years, CHF resulted from idiopathic dilated cardiomiopathy; these patients had been in severe CHF for 6 months, 3 years and 10 months, respectively, and 2 of them also had iatrogenic hyperthyroidism from prolonged amiodarone treatment. In 5 patients, aged 53, 71, 72, 72 and 73 years, CHF had lasted 4 to 10 years as a result of coronary artery disease, with repeated myocardial infarctions over the past 4 to 16 years. All had been treated with inotropic, diuretic and vasodilator agents in different combinations and all showed a diminishing response to drugs despite increasing dosages, ingravescent oligo-anuria and gain in body weight related to anasarcatic edemas, extreme heart enlargement and pulmonary congestion. Life expectancy was estimated to be less than 3 months in all cases. From the CNR Institute of Clinical Physiology Pisa and Patologia Medica and Hemodialysis Unit, University of Pisa. Pisa, Italy. This study was supported in part by a grant from the CNR Special Project of Biomedical and Clinical Engineering. Manuscript received June 5,1988; revised manuscript received August l&1986, accepted August 13,1986.
1, 1987
THE
AMERICAN
JOURNAL
OF CARDIOLOGY
Volume
59
379
ECUF was performed, filtering venous blood collected through a catheter positioned percutaneously in the inferior vena cava, by a high-permeability polyacrylonitrile membrane (dialyser surface 1.03 m2; cutoff point MW <20,000); venous return was accomplished by a second catheter in an antecubital vein. Treatment ranged from 1 session only in 1 case to 5 sessions (mean 3.4 sessions/patient) over a maximum of 9 days. Both number and repetition frequency were decided empirically on the basis of evolution of symptoms and response to drugs. Body weight loss ranged from 1.7 to 5.7 kg/session (mean 2.8), with a total loss of 10.9 to 14.7 kg [mean 11.5 kg/patient) in the subjects who had 2 to 5 sessions and of 3.5 kg in the patient who had 1 session only. During ECUF, all drug treatment was withdrawn in 5 cases; in 3 patients medication was continued, but in small doses. Clinical improvement was usually dramatic, particularly in regard to respiratory distress and refractory edemas. Urine output remained low during ECUF, but increased with resumption of treatment in moderate dosages. Body weight loss usually continued after ECUF, with an increase in urine output (at discharge mean total body weight loss was 13.4 kg [range 8 to 24). Pulmonary congestion was graded using a chest x-ray scoring approach4: score ranges at discharge from hospital (9.6 f 2.1) were significantly lower than those before ECUF (28.2 f 18.11, whereas changes in heart size were not significant. In our first patient (age 36 years, with dilated cardiomyopathy), 2 weeks after ECUF body weight increased again and urine output decreased despite treatment, with reappearance of respiratory distress and multifocal ventricular premature complexes. The patient died 20 days later. Patient 4, also with dilated cardiomyopathy, underwent successful heart transplantation 3 weeks after ECUF and is doing well 24 months later. Six subjects were discharged from the hospital 2 to 3 weeks after ECUF, all markedly improved with moderate medical treatment. They were followed at the outpatient clinic every 2 months and were instructed to contact the hospital to repeat ECUF at any sign of clinical worsening. In patients 2 and 7, ECUF (1 session) was repeated 4 and 2.5 months later, respectively, to restore electrolyte balance without fluid removal in patient 2 and to check relapse of symptoms in patient 7, with results similar to previous results. Improvement was maintained at home with moderate treatment and all 6 subjects resumed moderate physical activity. Six of them are still alive, 4,7, 9,9,10 and 24 months after ECUF. Quality of life was uniformly reported as markedly improved. One patient [age 72 years) died 1 year later from cerebrovascular stroke. We have no explanation for the pathophysiologic mechanisms of the observed effects. Our initial hypothesis that ECUF could simply replace excretion to maintain fluid balance in patients no longer responding to drugs does not explain the duration of improvement after ECUF. In these patients, a resetting of the hemodynamic and fluid balance mechanisms appears to have taken place; consequently, we believe that a
380
BRIEF REPORTS
functional disturbance was associated with structural heart damage in the inducement of intractable CHF. The factors responsible for it were removed by ultrafiltration, resulting in resetting of the mechanism on a more favorable cycle. These data agree with those reported by Page et a1,5 who suggested that in patients with terminal CHF refractory to medical treatment, ECUF may prolong and improve life. This could be particularly valuable in patients in whom heart transplantation is not immediately accessible both to improve the clinical standard of the patient before sur-
PercutaneousBalloonValvuloplasty of Mitral StenosisAided by CardiacUltrasound
gery and to prolong life expectancy while waiting for a heart donor. 1. Opie LH. Principles of theropy for congestive 1984;4:suppl A:199-208. 2. Gorlin R. Incidence, etiology and prognosis Rev Resp 1983;4:765-770.
heart failure.
Eur Heart
1
of heart failure. Cordiovasc
3. Ing TS. Chen WT, Daugirdas JI, Kwaan HC, Hans JE.Isolated ultrafiltration and new techniques of ultrafiltration during dialysis. Kidney Int 1980;18:577582. 4. Pistolesi M, Giuntini C. Assessment of extravascular lung water. Radio1 Clin North Am 1978;16:551-574,
5. Page E, Machecourt J, Dechelette E. Wolf JE, Bourlard P, Denis B. Traitment des insuffisances tion corporelle. Arch
cardiaques Ma1 Coeur
ovec oedemes r6froctoires 1984:77:1040-1045.
par ultrafiltra-
A 55year-old man with rest dyspnea due to known mitral stenosis was referred for percutaneous balloon valvuloplasty. After sedation with diazepam (IO mg) and under local anesthesia with xylocaine, the right femoral vein was cannulated with a No. 8Fr, 59-cmlong MuJJins sheath and dilator (U.S.C.I.), which were advanced via an 0.038-inch guidewire to the superior vena cava, where the wire was withdrawn. A standard Brockenbrough needle was advanced to the tip of the dilator, both needle and dilator were withdrawn to the Jimbus of the fossa ovalis of the atrial septum and the
needle, followed by the dilator and sheath, were advanced into the left atrium. The needle and dilator were then removed and a balloon-tipped 7Fr endhole catheter (Edwards, Inc.) was advanced through the sheath to the left atrium, across the mitral valve, through the left ventricle, across the aortic valve and into the descending aorta. An 0.038-inch 400-cm exchange wire (Cook, Inc.) was then inserted into the balloon catheter and passed through the descending aorta into the left femoral artery, The balloon catheter was then exchanged for a No. 9Fr catheter with an 8mm diameter, 3-cm-long balloon (Mansfield Scientific), which was advanced through the exchange wire across the interatrial septum and used to dilate the atrial septostomy. The 8-mm balloon catheter was then exchanged for a 9Fr catheter with a 20-mm-diameter, 3-cm-long balloon (Mansfield). In advancing the 20-mm balloon catheter, resistance was encountered at what was believed to be the site of the atria1 septum. A mild degree of balloon inflation carried out during 2-D echocardiographic imaging at this point disclosed that the catheter had crossed the atrial septum (Fig. 1, left]. When further advancement of the balloon catheter was obviated by more resistance, echocardiography showed that the catheter could not negotiate the mitral valve orifice (Fig. I, right). Using a combination of fhoroscopic and echocardiographic imaging, continued manipulation of the catheter resulted in successful negotiation of the stenotic mitral valve orifice (Fig. 2, left), after which balloon valvuloplasty was performed (Fig. 2, right). After valvuloplasty was performed, the mitral valve gradient decreased from 25 to 11 mm Hg, cardiac output increased to 4.5 Jiters/min, and calculated mitral valve orifice area increased from 0.7 to I.2 crn2. Pulmonary arterial pressure decreased from 641 22 mm Hg (mean 38) to 50/16 mm Hg (mean 30 mm Hg). The patient tolerated the procedure without difficulty. At 3-month follow-up examination, the patient had no rest dyspnea and had exertional dyspnea only during strenuous exercise.
From the Departments of Medicine (Cardiology] and Pediatrics [Cardiology). Tufts-New England Medical Center, Boston, Massachusetts. Manuscript received September 11, 1986, accepted September 15,1986.
The atria1 septum and the stenotic mitral valve constitute 2 potential sites of resistance to advancement of the larger valvular dilation catheters. The relatively short distance and sharp bend from the fossa ovalis site
NATESA G. PANDIAN, MD JEFFREY M. ISNER, MD THOMAS J. HOUGEN, MD MARK R. DESNOYERS, MD KEVIN MclNERNEY, BS DEEB N. SALEM, MD
R
ecent report@ have established the feasibility of percutaneous balloon dilation of stenotic mitral valves. The standard transseptal technique used for this procedure was modified by Lock et al2 to include dilation with an 8-mm balloon catheter of the ostium created in the atria1 septum. Successful transseptal delivery of the larger balloons required for mitral valve dilation depends on an adequate-sized atria1 septostomy; too small a defect may interfere with advancement of the valvular dilation catheter toward the mitral orifice. The present report describes the manner in which &dimensional (2-D] echocardiography was successfully used to monitor delivery of the valvular dilation catheter across the atria1 septum and through the mitral orifice.