Sustained cardiac diastolic changes elicited by ultrafiltration in patients with moderate congestive heart failure: pathophysiological correlates.

Abstract

Objective-To investigate the pathophysiological (cardiac fimction and physical performance) significance of clinically silent interstitial lung water accumulation in patients with moderate heart failure; to use isolated ultrafiltration as a means of extravascular fluid reabsorption. Design-Echocardiographic, Doppler, chest x-ray evaluations, and cardiopulmonary tests at baseline, soon after ultrafiltration (veno venous extracorporeal circuit), and four days, one month, and three months later. Setting-University institute of cardiology. Subjects-24 patients with heart failure due to idiopathic dilated cardiomyopathy or ischaemic myocardial disease with sinus rhythm and ejection fraction less than 35%. Twelve were randomised to ultrafiltration and 12 were taken as controls. Main outcome measures-Left ventricular systolic function (from ultrasonography); Doppler evaluation of mitral, tricuspid, and aortic flow and echoDoppler determination of cardiac output; radiological score of extravascular lung water; right and left ventricular filling pressures; oxygen consumption at peak exercise and exercise tolerance time in cardiopulmonary tests. Results-Soon after ultrafiltration (1976 (760) ml of fluid removed) the following was observed: a reduction in radiological score of extravascular lung water (from 15(1) to 9(1)) and of right (from 7*1 (2.3) to 2-3 (1.7) mm Hg) and left (from 17*6 (8-8) to 9-S (6.4) mm Hg) ventricular filling pressures; an increase in oxygen consumption at peak exercise (from (3.3) to 17-6 (2) mllminlkg) and of tolerance time (from 444 (138)

2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults

“…Provided that renal function stabilizes, small or moderate elevations of blood urea nitrogen and serum creatinine should not lead to efforts to minimize the intensity of therapy; however, if the degree of renal dysfunction is severe or if the edema becomes resistant to treatment, ultrafiltration or hemofiltration may be needed to achieve adequate control of fluid retention. 547, 548 The use of such mechanical methods of fluid removal can produce meaningful clinical bene fits in patients with diuretic-resistant HF and may restore responsiveness to conventional doses of loop diuretics.…”

ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

“…This strategy can elicit a marked increase in urine volume, but such a diuresis is frequently accompanied by worsening azotemia, especially if patients are also being treated with an ACEI. Provided that renal function stabilizes, small or moderate elevations of blood urea nitrogen and serum creatinine should not lead to efforts to minimize the intensity of therapy; however, if the degree of renal dysfunction is severe or if the edema becomes resistant to treatment, ultrafiltration or hemofiltration may be needed to achieve adequate control of fluid retention (489,490). The use of such mechanical methods of fluid removal can produce meaningful clinical benefits in patients with diuretic-resistant HF and may restore responsiveness to conventional doses of loop diuretics.…”

Effects of acute angiotensin‐converting enzyme inhibition on diastolic ventricular interaction in the dilated heart

“…All these Doppler findings are consistent with a reduction in LV end-diastolic pressure during our tests. 18,20,21 Thus, as suggested in previous studies, 22,23 in patients with heart failure in whom diastolic ventricular interaction and pericardial constraint are enhanced, the contribution of external forces to intracavitary LV end-diastolic pressure may explain rapid changes in mitral flow pattern as a consequence of maneuvers interfering with preload.…”