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Chinta VR, Theella NP, Raja JM, Rawal A, Bath A, Jones D, Ibrahim A, Asbeutah AAA, Adeboye AA, Akbilgic O, Khouzam RN, Stamper JJ, Jefferies JL. Outcomes of Ultrafiltration in community-based hospitals. Curr Probl Cardiol 2024; 49:102716. [PMID: 38909929 DOI: 10.1016/j.cpcardiol.2024.102716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 06/19/2024] [Indexed: 06/25/2024]
Abstract
OBJECTIVE We sought to examine outcomes of ultrafiltration in real world community-based hospital settings. BACKGROUND Ultrafiltration (UF) is an accepted therapeutic option for advanced decompensated heart failure (ADHF). the feasibility of UF in a community hospital setting, by general cardiologists in a start-up program had not been objectively evaluated. METHODS We retrospectively analyzed the first-year cohort of ADHF patients treated with UF from 10/1/2019 to 10/1/2020, which totaled 30 patients, utilizing the CHF Solutions Aquadex FlexFlow™ System with active UF rate titration. RESULTS Baseline patient characteristics were similar to RCTs: mean age 63, 73 % male; 27 % female; 53 % Caucasian; 47 % African American; 77 % had LVEF ≤ 40. The baseline mean serum creatinine (Cr) was 1.84 ±0.62 mg/dL, mean GFR of 36.95 ±9.60 ml/min. HF re-admission rates were not significantly different than prior studies (17.2 % at 30 d, 23.3 % at 60 d, but in our cohort, per patient HF re-admission rates were reduced significantly by 60 d (0.30 p = 0.017). CONCLUSION Our analysis showed success with UF in mainstream setting with reproducible results of significant volume loss without adverse renal effect, mitigation of recurrent Hdmissions, and remarkable subjective clinical benefit.
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Affiliation(s)
- Viswanath R Chinta
- Department of Advanced Heart Failure and Transplant Cardiology, HCA Houston HealthCare Medical Center, Houston, TX, USA.
| | - Neelima P Theella
- Department of Advanced Heart Failure and Transplant Cardiology, HCA Houston HealthCare Medical Center, Houston, TX, USA
| | - Joel M Raja
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aranyank Rawal
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anandbir Bath
- Ascension Borgess Hospital/Michigan State University Kalamazoo, Michigan, USA
| | - David Jones
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Atif Ibrahim
- North Mississippi Medical Center, Tupelo, MS, USA
| | | | | | - Oguz Akbilgic
- Department of Cardiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Rami N Khouzam
- Heart and Vascular institute, Grand Strand Medical Center, Myrtle Beach, SC, USA
| | - James J Stamper
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
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Arora RC, Brown JK, Chatterjee S, Gan TJ, Singh G, Tong MZ. Perioperative management of the vulnerable and failing right ventricle. Perioper Med (Lond) 2024; 13:40. [PMID: 38750602 PMCID: PMC11097429 DOI: 10.1186/s13741-024-00397-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024] Open
Abstract
Under recognition combined with suboptimal management of right ventricular (RV) dysfunction and failure is associated with significant perioperative morbidity and mortality. The contemporary perioperative team must be prepared with an approach for early recognition and prompt treatment. In this review, a consensus-proposed scoring system is described to provide a pragmatic approach for expeditious decision-making for these complex patients with a vulnerable RV. Importantly, this proposed scoring system incorporates the context of the planned surgical intervention. Further, as the operating room (OR) represents a unique environment where patients are susceptible to numerous insults, a practical approach to anesthetic management and monitoring both in the OR and in the intensive care unit is detailed. Lastly, an escalating approach to the management of RV failure and options for mechanical circulatory support is provided.
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Affiliation(s)
- R C Arora
- Harrington Heart and Vascular Institute - University Hospitals, Cleveland, OH, USA.
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA.
| | - J K Brown
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Chatterjee
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - T J Gan
- Division of Anesthesiology and Perioperative Medicine, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Singh
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
- Departments of Critical Care Medicine and Surgery, University of Alberta, Edmonton, AB, Canada
| | - M Z Tong
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Terpos V, Roumeliotis S, Georgianos PI, Papa E, Tsalikakis DG, Papachristou E, Liakopoulos V. Diuretics or ultrafiltration in the treatment of acute decompensated heart failure: An updated systematic review and meta-analysis. Ther Apher Dial 2024; 28:9-22. [PMID: 37469222 DOI: 10.1111/1744-9987.14037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Hospitalization for decompensated heart failure is a major public health issue. METHODS We performed a meta-analysis to summarize and analyze if there is a benefit in using ultrafiltration over diuretics in terms of reducing mortality or hospital readmissions, primarily and identified 10 randomized controlled trials (RCTs) including 941 patients. RESULTS Compared to diuretics, treatment with ultrafiltration was associated with a significant reduction in heart failure hospitalizations (risk ratio [RR]: 0.72; 95% confidence interval [CI]: 0.55-0.96, p = 0.02) and significant increase in weight and net fluid loss (mean difference [MD]: -1.55, CI: -2.36 to -0.74, p = 0.0002) and (MD: -2.10, CI: -3.32 to -0.89, p = 0.0007), respectively. There was no significant difference among treatments regarding the duration of hospitalization, the increase in serum creatinine levels, and mortality. CONCLUSION Among patients with decompensated heart failure, compared to diuretics, ultrafiltration is associated with reduced rehospitalizations and increased weight/net fluid loss.
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Affiliation(s)
- Vasileios Terpos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Roumeliotis
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis I Georgianos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Papa
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Tsalikakis
- Department of Electrical and Computer Engineering, University of Western Macedonia, Kozani, Greece
| | - Evangelos Papachristou
- Department of Nephrology and Renal Transplantation, Patras University Hospital, Patras, Greece
| | - Vassilios Liakopoulos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Ullah W, Sana MK, Mustafa HU, Sandhyavenu H, Hajduczok A, Mir T, Fischman DL, Shah M, Brailovsky Y, Rajapreyar IN. Safety and efficacy of ultrafiltration versus diuretics in patients with decompensated heart failure: A systematic review and meta-analysis. Eur J Intern Med 2022; 104:41-48. [PMID: 35644712 DOI: 10.1016/j.ejim.2022.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ultrafiltration (UF) is used for fluid removal patients with acute decompensated heart failure with reduced ejection fraction (HFrEF) refractory to diuretics. However, data on the relative merits of UF and diuretics are limited. METHODS Online databases were queried to identify clinical trials on the comparison of UF and diuretics. The major adverse cardiovascular (MACE) and its components (mortality and re-hospitalizations) were compared using the random-effects model to calculate the unadjusted odds ratio (OR) with its 95% confidence interval (CI). RESULTS A total of 10 clinical trials comprising 838 patients (413 UF, 425 diuretics) were included in the analysis. At a median follow-up of 90 days, there was no significant difference in the odds of MACE (OR 0.71, 95% CI 0.47-1.07) and all-cause mortality (OR 1.08, 95% CI 0.77-1.52) between patients undergoing UF compared with those receiving diuretics therapy. The need for emergency department visits (OR 1.05, 95% CI 0.38-2.90), all-cause admissions (OR 0.97, 95% CI 0.72-1.30) and heart failure-related re-hospitalization (OR 0.47, 95% CI 0.21-1.02) was also similar between the two groups. The in-hospital risk for hypotension (OR 0.49, 0.23-1.04) and post-therapy creatinine rise>0.3 mg/dL (OR 1.18, 95% CI 0.74-1.89) was also not significantly different between the UF and diuretics arms. A sensitivity analysis of MACE and mortality did not show any deviation from the pooled outcomes. CONCLUSIONS In patients with HFrEF, UF appears to be safe but might not provide significant benefits in terms of reducing the risk of mortality or readmission rates compared with those treated with diuretics.
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Affiliation(s)
- Waqas Ullah
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.
| | | | - Hamza Usman Mustafa
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | | | - Alexander Hajduczok
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | | | - David L Fischman
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Mahek Shah
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Yevgeniy Brailovsky
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Indranee N Rajapreyar
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
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Inpatient Diuretic Management of Acute Heart Failure: A Practical Review. Am J Cardiovasc Drugs 2021; 21:595-608. [PMID: 33709346 DOI: 10.1007/s40256-020-00463-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 02/08/2023]
Abstract
The inpatient treatment of acute heart failure (AHF) is aimed at achieving euvolemia, relieving symptoms, and reducing rehospitalization. Adequate treatment of AHF is rooted in understanding the pharmacokinetics and pharmacodynamics of select diuretic agents used to achieve decongestion. While loop diuretics remain the primary treatment of AHF, the dosing strategies of loop diuretics and the use of adjunct diuretic classes to augment clinical response can be complex. This review examines the latest strategies for diuretic management in patients with AHF, including dosing and monitoring strategies, interaction of diuretics with other medication classes, use adjunctive therapies, and assessing endpoints for diuretic. The goal of the review is to guide the reader through commonly encountered clinical scenarios and pitfalls in the diuretic management of patients with AHF.
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Ultrafiltration is better than diuretic therapy for volume-overloaded acute heart failure patients: a meta-analysis. Heart Fail Rev 2020; 26:577-585. [PMID: 33244656 PMCID: PMC8024232 DOI: 10.1007/s10741-020-10057-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 11/23/2022]
Abstract
Studies on the effectiveness of ultrafiltration (UF) in patients hospitalized with acute decompensated heart failure (ADHF) have led to heterogeneous study outcomes. This meta-analysis aimed to assess the impact of UF therapy in ADHF patients. We searched the medical literature to identify well-designed studies comparing UF with the usual diuretic therapy in this setting. Systematic evaluation of 8 randomized controlled trials enrolling 801 participants showed greater fluid removal (difference in means 1372.5 mL, 95% CI 849.6 to 1895.4 mL; p < 0.001), weight loss (difference in means 1.592 kg, 95% CI 1.039 to 2.144 kg; p < 0.001) and lower incidences of worsening heart failure (OR 0.63, 95% CI 0.43 to 0.94, p = 0.022) and rehospitalization for heart failure (OR 0.54, 95% CI 0.36 to 0.82, p = 0.003) without a difference in renal impairment (OR 1.386, 95% CI 0.870 to 2.209; p = 0.169) or all-cause mortality (OR 1.13, 95% CI 0.75 to 1.71, p = 0.546). UF increases fluid removal and weight loss and reduces rehospitalization and the risk of worsening heart failure in congestive patients, suggesting ultrafiltration as a safe and effective treatment option for volume-overloaded heart failure patients.
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