Advanced Decompensated Heart Failure Research Articles

Outcomes of Ultrafiltration in community-based hospitals

ObjectiveWe sought to examine outcomes of ultrafiltration in real world community-based hospital settings. BackgroundUltrafiltration (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. MethodsWe 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. ResultsBaseline 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). ConclusionOur 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.

A Comprehensive Appraisal of Risk Prediction Models for Cardiogenic Shock.

Despite advances in early revascularization, percutaneous hemodynamic support platforms, and systems of care, cardiogenic shock (CS) remains associated with a mortality rate higher than 50%. Several risk stratification models have been derived since the 1990 s to identify patients at high risk of adverse outcomes. Still, limited information is available on the differences between scoring systems and their relative applicability to both acute myocardial infarction and advanced decompensated heart failure CS. Thus, we reviewed the similarities, differences, and limitations of published CS risk prediction models and herein discuss their suitability to the contemporary management of CS care.

Use of Impella 5.0 with Axillary Approach as a Bridge to Decision in Advanced Decompensated Heart Failure

Cardiogenic shock is a spectrum and short term mechanical circulatory support devices such as VA ECMO and Impella 5.0 have been increasingly utilized as a salvage and bridge therapy. The objective of this study is to evaluate the use of these temporary support devices in patients with refractory cardiogenic shock. Retrospective review of all patients with an Impella 5.0 or EC-Pella between January 2018 to September 2019. A total of 39 patients were placed on Impella 5.0 and 17 of those received EC-Pella. Overall, patients were predominantly INTERMACS profile 1 (43%) or 2 (57%). Average age was 57 and length of stay was 28 days. Common indications included progressive decline on inotropic support, as an exit to wean from VA ECMO, and to evaluate right sided heart function to bridge to a durable LVAD. Overall survival of these patients is 74% (n= 29). Of the 39 Impella patients, 46% (n= 18) received a durable LVAD, 15% (n= 6) received OHT, 21% (n= 8) were a bridge to recovery, and 18% (n= 7) expired. The survival to discharge for patients with an LVAD was 84% (n=15), 100% for OHT (n= 6). Of the 10 total patients that expired, 3 patients died of RV failure post LVAD, and 7 died from lack of end-organ recovery..The survival to discharge rate was 90% for Impella patients that never required ECMO support during their admission. Alternatively, in the EC-Pella population, the survival to discharge was 53%. Axillary Impella 5.0 approach can be successfully used with excellent survival to discharge. With concomitant VA ECMO use the survival rate decreases, however, the patients were more acute with higher incidence of cardiac arrest, post cardiotomy shock, and increasing utilization of hemodialysis. This data needs to be validated prospectively through further data collection.

Safety of Initiation of Sacubitril/Valsartan in ICU Patients with Advanced Decompensated Heart Failure

Introduction Sacubitril/valsartan (S/V) is superior to enalapril in reducing mortality and morbidity in patients with chronic stable heart failure with reduced ejection fraction (HFrEF). The goal of this investigation was to determine if S/V could be used safely as an oral vasodilator when weaning intravenous vasoactive therapies. Methods Invasive hemodynamic data was prospectively collected from ten consecutive patients with Stage D HFrEF admitted to the heart failure intensive care unit (HF-ICU) for treatment of acute decompensated heart failure. All patients were admitted for pulmonary artery catheter hemodynamic guided therapy and were initiated on S/V. Results Ten patients were included in the cohort and were on either intravenous inotropes n=3 or sodium nitroprusside (SNP) n=7. Mean dose of SNP was 151 mcg/min, mean dose for dobutamine was 5 mcg/kg/min and milrinone dose was 0.5 mcg/kg/min. Mean age was 50 years old, with 4 females and 6 males. Three patients with ischemic cardiomyopathy, 7 non-ischemic cardiomyopathy. All patients were successfully weaned from inotropes or SNP and tolerated S/V initiation. Average mean arterial pressure of the cohort decreased from 88.3 to 80.6 mmHg (9% reduction), right atrial pressure decreased from 15.6 to 5 mmHg (70% reduction), mean pulmonary artery pressure decreased from 43.6 to 27.3 mmHg (37% reduction), pulmonary capillary wedge pressure decreased from 28.4 to 14.7 mmHg (48% reduction), mean cardiac index increased from 1.7 to 2.56 l/min/m2 (51% increase) and mixed venous saturation increased from 52.6 to 67.2% (22% increase). The detailed hemodynamic results for each patient are summarized in Table 1. S/V was well tolerated and hemodynamics were stable after weaning IV therapy. Conclusion Patients with cardiogenic shock tolerated initiation of S/V and subsequent successful weaning of intravenous vasodilator or inotropic therapy. These preliminary novel hemodynamic observations suggest S/V may be initiated safely in ICU patients and facilitate weaning from intravenous therapies.

A Quality Bundle to Support High-Risk Pediatric Ventricular Assist Device Implantation.

Pediatric ventricular assist device (VAD) implantation outcomes are increasingly promising for children with dilated cardiomyopathy and advanced decompensated heart failure (ADHF). VAD placement in patients with clinical features such as complex congenital cardiac anatomy, small body size, or major comorbidities remains problematic. These comorbidities have been traditionally prohibitive for VAD consideration leaving these children as a treatment-orphaned population. Here we describe the quality bundle surrounding these patients with ADHF considered high risk for VAD implantation at our institution. Over a 7-year period, a quality bundle aimed at the peri-operative care for children with high-risk features undergoing VAD implantation was incrementally implemented at a tertiary children's hospital. Patients were considered high risk if they were neonates (< 30days), had single-ventricle physiology, non-dilated cardiomyopathy, biventricular dysfunction, or significant comorbidities. The quality improvement bundle evolved to include (1) structured team-based peri-operative evaluation, (2) weekly VAD rounds addressing post-operative device performance, (3) standardized anticoagulation strategies, and (4) a multidisciplinary system for management challenges. These measures aimed to improve communication, standardize management, allow for ongoing process improvement, and incorporate principles of a high-reliability organization. Between January 2010 and December 2017, 98 patients underwent VAD implantation, 48 (49%) of which had high-risk comorbidities and a resultant cohort survival-to-transplant rate of 65%. We report on the evolution of a quality improvement program to expand the scope of VAD implantation to patients with high-risk clinical profiles. This quality bundle can serve as a template for future large-scale collaborations to improve outcomes in these treatment-orphaned subgroups.

Outpatient Weaning of Inotropes is Achievable in Patients with Advanced Heart Failure

Purpose Patients admitted with advanced decompensated systolic heart failure (ADHF) typically require inotropes . Those who cannot be bridged to advanced heart failure therapies are discharged home on inotropes (as a palliative measure or until eligible for advanced therapies). Continuous inotrope infusion exposes patients to increased risk of arrhythmias and mortality. It is unknown whether such patients can be weaned off inotropic support in an outpatient setting. Methods In a single-center observational study of patients admitted with ADHF between 2016-2018, we studied demographics, clinical history, physical exam data, and laboratory data. We determined functional status and compliance with medical therapies of patients who were successfully weaned off inotropes. Creatinine , electrolytes, vital signs, and physical exam findings were followed weekly/biweekly during weaning and followed post-wean for ≥60 days. Results 9 patients (mean age 49 y; 5 males) were successfully weaned off inotropes in an outpatient setting. All had been discharged home on milrinone or dobutamine infusion. Only 1 patient had ischemic cardiomyopathy ; 2 had required mechanical support during hospitalization. Median length of stay after inotrope initiation was 8 days with median 78 days on inotropes prior to weaning. 6 patients were started on sacubitril/valsartan, which was uptitrated during weaning, of whom 3 tolerated the maximum dose. The other patients were uptitrated on angiotensin converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARB). 60 days post-wean, all 9 patients reported doing well with NYHA Class IIIa (n=5), Class IV (n=1), and Class II (n=3) symptoms. On longitudinal follow-up, 1 patient was hospitalized 1-year post-wean, was subsequently restarted on inotropes and required heart transplantation . Conclusion With close monitoring and gentle uptitration of afterload-reducing agents, it is feasible to wean patients with ADHF off inotropes in an outpatient setting.

Prognosis and risk stratification in patients with decompensated heart failure receiving inotropic therapy

ObjectivesThe prognostic significance of transient use of inotropes has been sufficiently studied in recent heart failure (HF) populations. We hypothesised that risk stratification in these patients could contribute to patient...

Predictors of Positive Response to Resynchronization Therapy in Patients with Recurrent Episodes of Acutely Decompensated Advanced Heart Failure

Abstract Background: In just a few years, cardiac resynchronization therapy (CRT) has emerged as a key player in the treatment of advanced heart failure (HF). However, approximately 30% of patients with CRT device implantation do not achieve a favorable response. The purpose of the present study was to identify clinical, electrocardiographic, and echocardiographic predictors of a positive response to biventricular pacing in patients with advanced decompensated HF. Methods: This prospective, observational study involved 42 consecutive patients admitted in emergency settings in our clinic with HF in New York Heart Association (NYHA) functional class III/IV, with QRS duration ≥120 ms and left ventricle ejection fraction (LVEF) ≤35%, who underwent cardiac resynchronization therapy (CRT-P or CRT-D) between January 2010 and July 2014. Statistical analysis was performed using IBM SPSS statistical software. Results: The clinical response (improvement in NYHA class) was recorded in 6 patients (14.3%), while echocardiographic response (change in ejection fraction and/or in endsystolic or end-diastolic volumes) was recorded in 10 patients (23.8%). The most frequently observed type of response to CRT was the double (clinical plus echocardiographic) response, recorded in 23 out of 42 patients (54.8%). ROC analysis identified the absence of chronic renal disease and the duration from onset of symptoms to CRT implantation as good predictors for clinical improvement after CRT (AUC = 0.625, 95% CI: 0.400–0.850 for absence of renal failure and AUC = 0.516, 95% CI: 0.369–0.853 for symptoms duration). However, gender, age, duration from symptom onset, and comorbidities were not good predictors for the echocardiographic response (AUC &lt;0.600). Conclusions: CRT represents an important therapeutic option for selected patents with advanced decompensated HF and prolonged QRS interval; however, only some of the commonly used criteria can predict a favorable outcome in patients undergoing CRT.

The Role of Sodium Bicarbonate in the Management of Some Toxic Ingestions.

Adverse reactions to commonly prescribed medications and to substances of abuse may result in severe toxicity associated with increased morbidity and mortality. According to the Center for Disease Control, in 2013, at least 2113 human fatalities attributed to poisonings occurred in the United States of America. In this article, we review the data regarding the impact of systemic sodium bicarbonate administration in the management of certain poisonings including sodium channel blocker toxicities, salicylate overdose, and ingestion of some toxic alcohols and in various pharmacological toxicities. Based on the available literature and empiric experience, the administration of sodium bicarbonate appears to be beneficial in the management of a patient with the above-mentioned toxidromes. However, most of the available evidence originates from case reports, case series, and expert consensus recommendations. The potential mechanisms of sodium bicarbonate include high sodium load and the development of metabolic alkalosis with resultant decreased tissue penetration of the toxic substance with subsequent increased urinary excretion. While receiving sodium bicarbonate, patients must be monitored for the development of associated side effects including electrolyte abnormalities, the progression of metabolic alkalosis, volume overload, worsening respiratory status, and/or worsening metabolic acidosis. Patients with oliguric/anuric renal failure and advanced decompensated heart failure should not receive sodium bicarbonate.

Global myocardial oedema in advanced decompensated heart failure.

To use cardiac magnetic resonance (CMR) imaging with quantitative T2 mapping as surrogate for myocardial water content in patients with advanced decompensated heart failure (ADHF), compare these values with T2-values observed in chronic heart failure, and evaluate the change with decongestive therapy. Volumetric CMR measurements and quantitative T2 mapping were performed in 18 consecutive ADHF patients with clinical signs of volume overload. Eleven patients with stable heart failure were used as controls. Vasodilator therapy and diuretics were administered to achieve a pulmonary arterial wedge pressure (PAWP) of <18 mmHg and central venous pressure (CVP) of <12 mmHg, after which CMR was repeated. ADHF patients (62 ± 12 years; 89% male; left ventricular ejection fraction 23 ± 8%) presented with low cardiac index (2.08 ± 0.59 L/min/m2), high PAWP (25 ± 7 mmHg), and high CVP (14 ± 5 mmHg). After decongestion, the patients had a significant increase in cardiac index (+0.41 ± 0.53 L/min/m2; P = 0.005) and decreases in both PAWP (-9 ± 6 mmHg; P < 0.001) and CVP (-6 ± 5 mmHg; P < 0.001). At baseline, global left ventricular T2-values were higher in ADHF patients compared with controls (59.5 ± 4.6 vs. 54.7 ± 2.2 ms, respectively; P = 0.001). After decongestion, T2-values fell significantly to 55.9 ± 5.1 ms (P = 0.001), comparable with controls (P = 0.580). In contrast, psoas muscle T2-values were similar at baseline (38.6 ± 4.4 ms) vs. after decongestion (37.8 ± 4.8 ms; P = 0.397). Each 1 ms decrease in global left ventricular T2-value during decongestion was associated with a 1.14 ± 0.40 mmHg decrease in PAWP (P = 0.013), after correction for age and gender. Patients presenting with ADHF and volume overload have increased global left ventricular-but not psoas muscle-T2-values, which decrease with successful decongestion. Relief of myocardial oedema correlates with haemodynamic unloading.

Response and tolerance to oral vasodilator up-titration after intravenous vasodilator therapy in advanced decompensated heart failure.

The aim of this study was to assess the haemodynamic response and tolerance to aggressive oral hydralazine/isosorbide dinitrate (HYD/ISDN) up-titration after intravenous vasodilator therapy in advanced decompensated heart failure (ADHF). Medical records of 147 consecutive ADHF patients who underwent placement of a pulmonary artery catheter and received intravenous vasodilator therapy were reviewed. Intravenous sodium nitroprusside and sodium nitroglycerin as first-line agent for those with preserved blood pressures were utilized in 143 and 32 patients, respectively. Sixty-one percent of patients were converted to oral HYD/ISDN combination therapy through a standardized conversion protocol. These patients had a significantly higher admission mean pulmonary arterial wedge pressure compared with patients not converted (28 ± 7 vs. 25 ± 8 mmHg, respectively; P-value 0.024). Beneficial haemodynamic response to decongestive therapy, defined as low cardiac filling pressures and cardiac index ≥2.20 L/min/m(2) without emergent hypotension, was achieved in 32% and 29% of patients who did or did not receive oral HYD/ISDN, respectively (P-value 0.762). HYD/ISDN dosing was progressively and consistently decreased up to the moment of hospital discharge and during outpatient follow-up, primarily due to incident hypotension. The use of a standardized haemodynamically guided up-titration protocol for conversion from intravenous to oral vasodilators may warrant subsequent dose reductions upon stabilization.

Clinical and prognostic role of ammonia in advanced decompensated heart failure. The cardio-abdominal syndrome?

BackgroundAdvanced heart failure is associated with end-organ damage. Recent literature suggested an intriguing crosstalk between failing heart, abdomen and kidneys. Venous ammonia, as a by-product of the gut, could be a marker of abdominal injury in heart failure patients.The aim of the study was to investigate the clinical and prognostic role of ammonia in patients with advanced decompensated heart failure (ADHF). Methods & results90 patients admitted with ADHF were prospectively studied. The prognostic role of ammonia at admission was evaluated. Primary end-points were: a composite of cardiac death, urgent heart transplantation and mechanical circulatory support at 3months and need for renal replacement therapies (RRT).In the study cohort (age 59.0±12.0years, FE 21.6±9.0%, INTERMACS profile 3.7±0.9, creatinine 1.71±0.95mg/dl) 27 patients (30%) underwent the cardiac composite endpoint, while 9 patients (10%) needed RRT.At ROC curve analysis ammonia ≥130μg/dl (abdominal damage) showed the best diagnostic accuracy. At multivariate analysis abdominal damage predicted the cardiac composite endpoint. Abdominal damage further increased risk among patient with cold profile at admission (HR 2.7, 95% CI 1.1–7.0, p=0.046).At multivariate analysis abdominal damage also predicted need for RRT (OR 10.8, 95% CI 1.5–75.8, p=0.017). The combined use of estimated right atrial pressure and ammonia showed the highest diagnostic accuracy and a very high specificity in prediction of need for RRT. ConclusionIn a selected population admitted for ADHF ammonia, as a marker of abdominal derangement, predicted adverse cardiac events and need for RRT.

CARDIAC POWER INDEX IN ADVANCED DECOMPENSATED HEART FAILURE: INSIGHTS FROM THE ESCAPE TRIAL

Cardiac power (CP) is the rate of hydraulic work done by the heart. It is prognostic in acute ischemia, but its role advanced decompensated heart failure (ADHF) is unclear. We analyzed the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial

A disproportionate elevation in right ventricular filling pressure, in relation to left ventricular filling pressure, is associated with renal impairment and increased mortality in advanced decompensated heart failure

Discordance between left- and right-sided filling pressures occurs in a subset of patients presenting with acute decompensated heart failure (ADHF). We hypothesized that a disproportionately increased right atrial pressure (RAP) relative to the pulmonary capillary wedge pressure (PCWP) would be associated with both renal dysfunction and mortality in ADHF. A total of 367 patients admitted with ADHF with elevated intracardiac filling pressures were treated with intensive medical therapy guided by invasive hemodynamic monitoring. Baseline characteristics, hemodynamics, and renal function at admission were stratified by RAP/PCWP quartiles. The association of RAP/PCWP quartile with all-cause mortality after a median follow-up of 2.4 years was assessed in univariable and multivariable models, which included adjustment for the RAP. The median RAP/PCWP was 0.58 (interquartile range 0.43-0.75). Increasing RAP/PCWP was inversely associated with estimated glomerular filtration rate at baseline and with treatment (P < .0001) independently of RAP. High RAP/PCWP was associated with increased mortality (quartile 4 vs 1: hazard ratio [95% CI] 2.1 [1.3-3.5], P = .002). The association of RAP/PCWP with mortality persisted after adjustment for age, gender, mean arterial pressure, RAP, cardiac index, pulmonary vascular resistance, and estimated glomerular filtration rate (hazard ratio 2.4 [1.4-3.9], P = .007). A disproportionate increase in right to left ventricular filling pressures is associated with renal dysfunction and mortality, independently of the right atrial pressure.

Abstract 18506: Relief of Myocardial Edema in Advanced Decompensated Heart Failure is Associated with Improved Left Ventricular Systolic and Diastolic Function

Introduction: Cardiac magnetic resonance (CMR) imaging with quantitative T2-mapping allows identi[[Unable to Display Character: &amp;#64257;]]cation of myocardial edema, improving risk-stratification in acute coronary syndromes and myocarditis. Hypothesis: Global myocardial edema contributes to left ventricular (LV) dysfunction in advanced decompensated heart failure (ADHF). Methods: CMR with quantitative T2-mapping was performed in consecutive ADHF patients (n=17) undergoing right heart catheterization for worsening dyspnea and volume overload. Patients received vasodilators and diuretics to achieve pulmonary capillary wedge pressure (PCWP) ≤18 mmHg and central venous pressure (CVP) ≤10 mmHg, while maintaining mean arterial pressure ≥65 mmHg. After reaching hemodynamic targets, the pulmonary arterial catheter was removed and CMR imaging repeated. Changes in LV T2-values, hemodynamics, and CMR volumetric measurements were compared. Results: Study patients (64±11 years, male 88%, LV ejection fraction 23±8%, ischemic cardiomyopathy 50%) received decongestive treatment during 5±2 days. PCWP and CVP decreased from 25±7 to 17±4 mmHg and 13±6 to 7±3 mmHg, respectively (p&lt;0.001 for both), while cardiac index increased from 2.14±0.60 to 2.58±0.49 L/min/m 2 (p=0.012). LV T2-values dropped consistently from 59.6±4.9 ms to 56.3±5.2 ms after decongestion (p=0.002; Figure). Decreasing LV T2-values correlated well to both decreasing PCWP (r=0.75; p=0.001) and increasing cardiac index (r=0.58; p=0.023). Although LV end-diastolic volume index (142±31 to 135±34 mL/m 2 ; p=0.033) and end-systolic volume index (110±29 to 99±33 mL/m 2 ; p=0.001) both decreased significantly, the extent of these changes were not correlated to changing T2-values (r=0 and 0.11, respectively; p=ns). Conclusions: Global LV myocardial edema is observed in ADHF and reversible with successful decongestive therapy. Relief of myocardial edema strongly correlates with improvements in systolic and diastolic function.

Prognostic significance of dilated inferior vena cava in advanced decompensated heart failure.

Dilated inferior vena cava (IVC) is prevalent among patients with heart failure (HF), but whether its presence predicts worsening renal function (WRF) or adverse outcomes is unclear. This cohort study analyzed patients with left ventricular ejection fraction <40 % and repeated hospitalizations (≥2 times) for HF between August 2009 and August 2011. The study endpoints were death and HF re-hospitalization. Among baseline parameters, IVC diameter was the most powerful predictor for the development of WRF (area under the curve = 0.795, cut-off value = 20.5 mm). During the 2-year follow-up, 36 patients (49 %) were re-hospitalized for HF and 14 patients (19 %) died. The event rates were significantly greater in the WRF group than in the non-WRF group (71 vs. 30 %, P < 0.001 for HF re-hospitalization; 29 vs. 10 %, P = 0.03 for death). In Cox regression model, the risk of combined end-points was increased in patients with aging, elevated blood urine nitrogen, IVC >21 mm, and WRF. When adjusted for confounding factors, IVC >21 mm [hazard ratio (HR) 3.73, 95 % confidence interval (CI) 1.66-8.34] and WRF (HR 2.68, 95 % CI 1.07-6.75) were significant predictors for adverse outcomes. In patients with advanced decompensated HF, dilated IVC (>21 mm) predicted the development of WRF and could be a predictor for adverse outcomes.

The ADHF/NT-proBNP risk score to predict 1-year mortality in hospitalized patients with advanced decompensated heart failure

The acute decompensated heart failure/N-terminal pro-B-type natriuretic peptide (ADHF/NT-proBNP) score is a validated risk scoring system that predicts mortality in hospitalized heart failure patients with a wide range of left ventricular ejection fractions (LVEFs). We sought to assess discrimination and calibration of the score when applied to patients with advanced decompensated heart failure (AHF). We studied 445 patients hospitalized for AHF, defined by the presence of severe symptoms of worsening HF at admission, severely depressed LVEF, and the need for intravenous diuretic and/or inotropic drugs. The primary outcome was cumulative (in-hospital and post-discharge) mortality and post-discharge 1-year mortality. Separate analyses were performed for patients aged ≤ 70 years. A Seattle Heart Failure Score (SHFS) was calculated for each patient discharged alive. During follow-up, 144 patients (32.4%) died, and 69 (15.5%) underwent heart transplantation (HT) or ventricular assist device (VAD) implantation. After accounting for the competing events (VAD/HT), the ADHF/NT-proBNP score's C-statistic for cumulative mortality was 0.738 in the overall cohort and 0.771 in patients aged ≤ 70 years. The C-statistic for post-discharge mortality was 0.741 and 0.751, respectively. Adding prior (≤6 months) hospitalizations for HF to the score increased the C-statistic for post-discharge mortality to 0.759 in the overall cohort and to 0.774 in patients aged ≤ 70 years. Predicted and observed mortality rates by quartiles of score were highly correlated. The SHFS demonstrated adequate discrimination but underestimated the risk. The ADHF/NT-proBNP risk calculator is available at http://www.fsm.it/fsm/file/NTproBNPscore.zip. Our data suggest that the ADHF/NT-proBNP score may efficiently predict mortality in patients hospitalized with AHF.

Peritoneal ultrafiltration in patients with advanced decompensated heart failure.

The aim of the Best Practice guidelines on peritoneal ultrafiltration (UF) in patients with treatment-resistant advanced decompensated heart failure (TR-AHDF) is to achieve a common approach to the management of decompensated heart failure in those situations in which all conventional treatment options have been unsuccessful, and to stimulate a closer cooperation between nephrologists and cardiologists. The standardization of the case series of different centers would allow a better definition of the results published in the literature, without which they are nothing more than anecdotes. TR-AHDF is characterized by the persistence of severe symptoms even when all possible pharmacological and surgical options have been exhausted. These patients are often treated with methods that allow extracorporeal UF - slow continuous ultrafiltration (SCUF) and continuous renal replacement therapy (CRRT) - which have to be performed in hospital facilities. Peritoneal ultrafiltration (PUF) can be considered a treatment option in patients with TR-AHDF when, despite the fact that all treatment options have been used, patients meet the following criteria: • stage D decompensated heart failure (ACC/AHA classification); • INTERMACS level 4 decompensated heart failure; • INTERMACS frequent flyer profile; • chronic renal failure (estimated glomerular filtration rate <50 ml/min per 1.73 m2: KDOQI classification stage 3 chronic kidney disease); • no obvious contraindications to peritoneal UF. PUF treatment modes are derived from the treatment regimens proposed by various authors to obtain systemic UF in patients with severe decompensated heart failure, using manual and automated incremental peritoneal dialysis involving various glucose concentrations in addition to the single icodextrin exchange. These guidelines also identify a minimum set of tests and procedures for the follow-up phase, to be supplemented, according to the center's resources and policy, with other tests that are less routine or more complex also from a logistic/organizational standpoint, emphasizing the need for the patient's clinical and treatment program to involve both the nephrologist and the cardiologist. The pathophysiological aspects of a deterioration in kidney function in patients with decompensated heart failure are also considered, and the results of PUF in patients with decompensated heart failure reported in the various case series are reviewed.

Dose Titration Following Stabilization with Vasodilator Therapy in Contemporary Patients with Advanced Decompensated Heart Failure

Dose Titration Following Stabilization with Vasodilator Therapy in Contemporary Patients with Advanced Decompensated Heart Failure

Baroreflex sensitivity and heart rate variability are enhanced in patients with anorexia nervosa

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