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Background: Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of peritoneal dialysis in patients with acute decompensated heart failure complicated by acute cardiorenal syndrome. Methods: We randomly assigned a total of 88 patients with type 1 acute cardiorenal syndrome to a strategy of ultrafiltration therapy (44 patients) or tidal peritoneal dialysis (44 patients). The primary endpoint was the change from baseline in the serum creatinine level and left ventricular function represented as ejection fraction, as assessed 72 and 120 h after random assignment. Patients were followed for 90 days after discharge from the hospital. Results: Ultrafiltration therapy was inferior to tidal peritoneal dialysis therapy with respect to the primary endpoint of the change in the serum creatinine levels at 72 and 120 h ( p = 0.041) and ejection fraction at 72 and 120 h after enrollment ( p = 0.044 and p = 0.032), owing to both an increase in the creatinine level in the ultrafiltration therapy group and a decrease in its level in the tidal peritoneal dialysis group. At 120 h, the mean change in the creatinine level was 1.4 ± 0.5 mg/dL in the ultrafiltration therapy group, as compared with 2.4 ± 1.3 mg/dL in the tidal peritoneal dialysis group ( p = 0.023). At 72 and 120 h, there was a significant difference in weight loss between patients in the ultrafiltration therapy group and those in the tidal peritoneal dialysis group ( p = 0.025). Net fluid loss was also greater in tidal peritoneal dialysis patients ( p = 0.018). Adverse events were more observed in the ultrafiltration therapy group ( p = 0.007). At 90 days post-discharge, tidal peritoneal dialysis patients had fewer rehospitalization for heart failure (14.3% vs 32.5%, p = 0.022). Conclusion: Tidal peritoneal dialysis is a safe and effective means for removing toxins and large quantities of excess fluid from patients with intractable heart failure. In patients with cardiorenal syndrome type 1, the use of tidal peritoneal dialysis was superior to ultrafiltration therapy for the preservation of renal function, improvement of cardiac function, and net fluid loss. Ultrafiltration therapy was associated with a higher rate of adverse events.

The Valsalva maneuver is an easily performed maneuver with an interesting hemodynamic effect which can be used to aid accurate echocardiographic diagnosis. However, correct adequate performance is often missed. Here, we aim to describe the performance of an adequate Valsalva maneuver and the correct interpretation of its effect. The Valsalva hemodynamic effect consists of four basic phases which can be used in echocardiography to yield an accurate diagnosis. Valsalva is used to decrease preload and provoke left ventricular outflow tract (LVOT) gradient in dynamic LVOT obstruction. In addition, a decrease in E/A ratio in mitral inflow >50 % with Valsalva correlates with increased LV filling pressure and diastolic dysfunction. Valsalva also momentarily increases RA pressure and helps to unmask a patent foramen ovale with the use of saline contrast.

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Given the increasing numbers of cardiac device implantations worldwide, it is important to determine whether permanent endocardial leads across the tricuspid valve can promote tricuspid regurgitation (TR). Virtually all current data is retrospective, and indicates a signal of TR being increased after permanent lead implantation. However, the precise incidence of moderate or greater TR post-procedure, the exact mechanisms (mechanical, traumatic, functional), and the hemodynamic burden and clinical effects of this putative increase in TR, remain uncertain. We have therefore designed a multicenter, international, prospective study of 300 consecutive patients (recruitment completed, baseline data presented) who will undergo echocardiography and clinical assessment prior to, and at 1-year post device insertion. This prospective study will help determine whether cardiac device-associated TR is real, what are its potential mechanisms, and whether it has an important clinical impact on cardiac device patients.

BackgroundEstablishment of thromboembolism prevention remains a challenge despite the widespread consensus that thromboprophylaxis safely reduces patient morbidity and mortality. Dabigatran is a nonvitamin K antagonist oral anticoagulant (NOAC) which reduces the risk of thromboembolism. Proper dosing is important to achieve the maximum prophylactic benefit with a maintained safety profile.ObjectiveTo evaluate the appropriateness of dabigatran dosing for stroke and systemic embolism prevention in patients with nonvalvular atrial fibrillation (NVAF).MethodsThis is a retrospective cohort study of adults with NVAF. The data were collected from the electronic filing system of the hospital. Patients receiving dabigatran therapy were divided into two treatment groups according to the dose of dabigatran received. The indications for dabigatran as an oral direct anticoagulant, including age, risk of bleeding, creatinine clearance (CrCl), were collected. Appropriateness of dose reduction included any of the following factors: HAS-BLED score >2 points, age ≥75 years, or CrCl of 30–50 mL/min. The two groups were evaluated according to dose appropriateness.ResultsDabigatran dose of 110 mg was found to be inappropriately low in a large number of patients (31.3%). Multivariate regression analysis showed significant association of age and dose appropriateness (p < 0.001).ConclusionThis study revealed inappropriate prescription of reduced doses of dabigatran in a large number of patients. Age was identified as the main driving factor for underdosing. Physicians’ and pharmacists’ awareness regarding this type of high-risk medication should be improved to ensure appropriate and safe use of this commonly used drug.

Graphical abstract

We are summarizing the recommendations for the use of Echocardiography in patients during COVID-19 pandemic. The patient risk for COVID-19 should be assessed according to the Saudi CDC guidelines. Echocardiography should only be performed of considered appropriate and will likely alter the clinical decision. In COVID-19 suspected/ confirmed patients, echocardiography study should be performed bedside and in infection control approved area with airborne precaution. Limited focused imaging is recommended to minimize contact time. A dedicated machine for COVID-19 suspected/confirmed cases is recommended. Transesophageal echocardiography is considered an aerosol generating procedure; therefore, an alternative modality should be strongly considered. In COVID-19 suspected/ confirmed patients, a transesophageal echocardiogram should be done only under strict airborne precaution. In low risk patient for COVID-19, Transesophageal echocardiography should be done with a minimum of droplet precaution, however; N95 respirator is preferred to surgical mask in this situation.