Refractory Chronic Heart Failure Research Articles

Pediatric mechanical circulatory support: pathophysiology of pediatric hemostasis and postoperative management algorithms

Chronic heart failure (CHF) against the background of congenital heart disease, mostly in early childhood, or various forms of cardiomyopathies, more common in teenage age, represents an important cause of morbidity and mortality in the pediatric population [1, 2]. Due to the increase in the number of patients suffering from refractory end-stage CHF over the last two decades, and the current shortage of donor organs in pediatric practice, the issue of long-term mechanical circulatory support (MCS) is becoming increasingly a pressing problem. Patient management is a multidisciplinary task, since prolonged use of anticoagulant and antiplatelet therapy to prevent ventricular thrombosis has potentially life-threatening complications - acute hemorrhagic stroke and bleeding of varying severity.

Closing the Digitalis Divide: Back to the Basics of Randomized Controlled Trials.

Publishe d decades after several randomized controlled trials (RCT) demonstrating decreased hospitalizations and no effect on all-cause mortality with digoxin use, a series of meta-analyses linking digoxin treatment and mortality have contributed to a narrower application of this medication for the management of heart failure (HF) and atrial fibrillation (AF). Given the conflicting data from the earlier RCTs and more recent meta-analyses, there is a growing polarization among providers for and against the use of digoxin in managing these conditions. To help close this divide, we provide a perspective on the literature with special attention to the quality of both older and more recent studies on this subject. The data from the highest quality studies we have, RCTs, suggest that digoxin use in patients with HF and/or AF is associated with improvement in several areas of outcomes including functional capacity, symptom management, reduced hospitalizations, fewer deaths due to HF, and treatment of refractory chronic heart failure with rEF, and may even have overall mortality benefit when serum digoxin concentrations are within therapeutic range. These effects are more pronounced in patients with EF < 25% and NYHA Class II-IV and at highest risk for hospitalization. As the risk of confounding factors was minimized by the study design, the likelihood that positive outcomes were identified with digoxin use increased. Clinicians and researchers need further adequately designed and powered RCTs exploring the connection between digoxin therapy and mortality, hospitalizations, and symptom management.

The Correlation between Common Variable Immunodeficiency and Atrial Fibrillation: Cardiac Implantable Electronic Devices‐associated infection by Stenotrophomonas maltophilia: A case report

BackgroundCommon variable immunodeficiency (CVID) is associated with systemic infections and autoimmune diseases which may elicit and perpetuate atrial fibrillation via inflammatory and oxidative mechanisms. CVID patients with early‐onset atrial fibrillation (AF) and chronic heart failure (CHF) are refractory to standardized cardiac ablation and frequently need sophisticated cardiac resynchronization therapy. Moreover, CVID‐CHF patients with cardiac implantable electronic devices (CIEDs) are vulnerable to opportunistic infection, especially Stenotrophomonas maltophilia bacteremia, which has high resistance to a variety of empirical antibiotics against gram negative bacteremia.Case presentation31 year‐old female with a past medical history of chronic refractory AF, CHF, thyroid cancer, non‐Hodgkin lymphoma, and factor V deficiency presented to the hospital with a fever of 104.0F for 2 days after recent dual‐chamber biventricular defibrillator replacement 2 weeks ago. 2 months ago, the patient was diagnosed with CVID due to recurrent cardiopulmonary infections. Upon this admission, the patient’s blood culture demonstrated S. maltophilia which was likely from the complications of CIEDs placement.ConclusionEarly‐onset Atrial fibrillation in young population may be a feature of CVID. Early recognition of CVID in these patients, especially with comorbidity of CHF, can mitigate the progression of AF with antioxidants as well as promptly identify and manage CIEDs‐associated infections, such as S. maltophilia.Figure 1

The Role of Levosimendan Infusion in Improving Renal Function in Worsening Type II Cardio-Renal Syndrome

The cardio-renal syndrome (CRS) includes a variety of pathologic conditions (acute or chronic) where the primary failing organ can be either the heart or the kidney. We present three cases of heart failure (HF) patients hospitalized for acute decompensation, who presented a CRS type II rapidly worsening after high doses of furosemide infusion. METHODS: From June 2015 to March 2016 all patients admitted to our Department for chronic refractory heart failure (NYHA class IV), underwent a determination of BNP and other laboratory tests (creatinine, GFR, haemoglobin), echocardiogram, non-invasive cardiac output measurement and 6 min walking test. Patients underwent a single infusion of levosimendan in case of CRS type II, at 0.1 µg/kg/min for 24-36 hours. Clinical / laboratory evaluation was repeated 24 hours and 1 week after infusion of the drug. RESULTS: Patients treated with levosimendan allowed the reduction of loop diuretics dose, because of the restoration of renal function. Body weight and peripheral edema were progressively reduced, and cardiac output improved. At discharge, exercise capacity significantly improved, functional class proved to be in NYHA class II-III, renal function and neurohormonal assessment (BNP) ameliorated. At one-month follow-up the clinical conditions remained stable as well as the parameters of renal function and plasma BNP. CONCLUSION: This clinical experience demonstrated that one of most frequent and dangerous evolution of renal impairment (development of Acute Kidney Injury) might be improved by using a single dose of levosimendan, which has a proved effect in improving cardiac function and urine output.

Effect of Footbath Therapy in Patients with Refractory Chronic Heart Failure

Background: Waon therapy has been shown to improve symptoms, cardiac function and prognosis in patients with chronic heart failure (CHF). We aim to investigate the utility of a convenient thermal therapy involving a footbath in patients with refractory CHF. Method: We enrolled ten patients who satisfied the following criteria: New York Heart Association (NYHA) functional class III or IV, LVEF <40%, and refractory to the conventional therapy. All patients underwent the footbath therapy daily for 2 weeks. Results: Blood pressure and heart rate did not differ during the footbath therapy. Footbath therapy significantly improved the NHYA functional class (p=0.02), plasma BNP level (1319.3 ± 812.4 vs 615.6 ± 490.4 pg/ml, p=0.04), and %FMD (3.1 ± 2.7 vs. 6.6 ± 4.1 pg/ml, p=0.04). In contrast, there was no significant change in LVEF (19.6 ± 10.9 vs. 22.3 ± 9.0 %, p=0.09). Conclusion: Footbath therapy could improve the status of CHF by improving the endothelial function. We think footbath therapy is a novel and convenient non-pharmacological treatment for patients with refractory CHF.

Percutaneous mitral valve repair: The last chance for symptoms improvement in advanced refractory chronic heart failure?

BackgroundThe role of percutaneous mitral valve repair (PMVR) in patients with end-stage heart failure (HF) and functional mitral regurgitation (FMR) is unclear. MethodsSeventy-five consecutive patients with FMR grade≥3+ and severe HF symptoms despite optimal medical therapy and resynchronization therapy underwent PMVR with the MitraClip system (Abbott, Abbott Park, IL, USA) at 3 centers. Clinical evaluation, echocardiography and pro-BNP measurement were performed at baseline and at 6-month. ResultsMean age was 67±11years, logistic EuroSCORE=23±18%, left ventricle ejection fraction (LVEF) 30±9%. In 6 patients (8%) PMVR was performed as a bridge to heart transplant; many patients were dependent from iv diuretics and/or inotropes. Rate of serious adverse in-hospital events was 1.3% (1 patient who died after conversion to cardiac surgery). Sixty-three patients (84%) were discharged with MR≤2+. At 6-month, 4 patients died (5%), 80% had MR≤2+ and 75% were in New York Heart Association class ≤II. Median pro-BNP decreased from 4395pg/ml to 2594pg/ml (p=0.04). There were no significant changes in LV end-diastolic volume (222±75ml vs. 217±79, p=0.19), end-systolic volume (LVESV, 154±66ml vs. 156±69, p=0.54) and LVEF (30±9% vs. 30±12%, p=0.86). Significant reverse remodeling (reduction of LVESV≥10%) was observed in 25%, without apparent association with baseline characteristics. The number of hospitalizations for HF in comparison with the 6months before PMVR were reduced from 1.1±0.8 to 0.3±0.6 (p<0.001). ConclusionsIn extreme risk HF patients with FMR, PMVR improved symptoms and reduced re-hospitalization and pro-BNP levels at 6months, despite the lack of LV reverse remodeling.

Peritoneal Dialysis Reduces the Number of Hospitalization Days in Heart Failure Patients Refractory to Diuretics

Previous small studies have reported favorable results of peritoneal dialysis (PD) in the setting of chronic refractory heart failure (CRHF). We evaluated the impact of PD in a larger cohort of patients with CHRF where end-stage renal disease was excluded. ♢ All patients who received PD therapy for CRHF between January 1995 and December 2010 in two medical centers in France were included in this retrospective study. Baseline characteristics were compared with clinical parameters during the first year after initiation of PD. Mortality, safety, and sustainability of PD were also analyzed. ♢ The 126 patients included had a mean age of 72 ± 11 years and an estimated glomerular filtration rate of 33.5 ± 15.1 mL/min/1.73 m2. Mean time on PD was 16 ± 16.6 months. During the first year, patients with a left ventricular ejection fraction (LVEF) of 30% or less experienced improvement in cardiac function (30% ± 10% vs 20% ± 6%, p < 0.0001). We observed a significant reduction in the number of days of hospitalization for acute decompensated heart failure after PD initiation (3.3 ± 2.6 days/patient-month vs 0.3 ± 0.5 days/patient-month, p < 0.0001). One-year mortality was 42%. ♢ In CRHF, PD significantly reduces the number of days of hospitalization for acute heart failure. Improved LVEF may have led to the comparatively good 1-year survival in this cohort.

Intra-renal Artery Ablation and Spinal Cord Stimulation for Drug Refractory Chronic Heart Failure

In congestive heart failure (CHF), the sympathetic nervous system is activated for initial compensation for the depressed heart function and preservation of cardiovascular homeostasis. However, its long-term activation has deleterious effects leading to cardiac decompensation and heart failure progression. Chronic beta-blocker therapy reverses left ventricular remodeling and improves survival.

Efficacy of regional renal nerve blockade in patients with chronic refractory heart failure

Background Increased renal sympathetic nerve activity can result in diuretic resistance in patients with chronic congestive heart failure. We investigated the effect of regional renal nerve blockade on the patients with chronic refractory heart failure and diuretic resistance. Methods Eighteen patients with chronic refractory heart failure were enrolled (mean age (64±11) years). The patients were randomly divided into two groups (renal nerve blockade group and standard therapy group, n=9 each). Renal nerve blockade was performed by percutaneous injection of local anaesthetic under computed tomographic guidance. Heart rate, mean arterial blood pressure, plasma and urine electrolytes, neurohormones, factional excretion of sodium (FENa), 24-hour urine volume were monitored at baseline and the first 24 hours after therapy. Dyspnea and oedema were also evaluated. The major adverse cardiovascular events (MACE), plasma brain natriuretic peptide (BNP) level and left ventricular ejection fraction (LVEF) were compared between the two groups during the 3-12 months follow-up period. Results No complication was observed during the acute phase of renal nerve blockade. After renal nerve blockade, the 24-hour urine volume and FENa were significantly increased, while the level of plasma rennin, angiotensin II, aldosterone, BNP and atrial natriuretic peptide as well as dyspnea and oedema were significantly reduced in renal nerve blockade group compared with baseline and standard therapy group. During three to 12 months of follow-up, the rate of MACE and plasma BNP level were significantly lower, while LVEF was significantly higher in renal nerve blockade group than those in standard therapy group. Conclusion Regional renal nerve blockade may be a safe and effective treatment for patients with chronic refractory heart failure.

Peritoneal dialysis relieves clinical symptoms and is well tolerated in patients with refractory heart failure and chronic kidney disease

The aim of the study was to evaluate the efficacy and clinical outcome of peritoneal dialysis (PD) treatment in patients with severe refractory heart failure (HF) and chronic kidney disease (CKD). The PD treatment was performed in 118 patients [49.2% New York Heart Association (NYHA) III and 50.8% NYHA IV] with a mean age of 73.2 ± 11.4 years as an in-centre-based and intermittent automated PD at least three times per week for 12 h per session and followed up for 1.11 ± 1.17 years. The functional status of those surviving for 6 months improved (P < 0.0001): 18 (32.1%) of all 60 patients with NYHA IV at baseline died within 6 months, 3 (5.4%) converted to NYHA III, 33 (58.9%) to NYHA II, and 2 (3.6%) to NYHA I. In all 58 patients with NYHA III at baseline, 14 (25.0%) died within 6 months, 27 (48.2%) converted to NYHA II, 12 (21.4%) to NYHA I, and 3 (5.4%) showed no improvement. In those surviving for 6 months, fluid overload was significantly reduced as body weight decreased, from 78.7 [95% confidence interval (CI) 75.8-81.7] to 74.7 (71.5-77.9) after 6 months after multiple imputation (P < 0.001). The overall survival rates after 3, 6, and 12 months were 77% (95% CI 70-85), 71% (95% CI 62-79), and 55% (95% CI 45-64). In the multivariate analyses, age, diabetes mellitus, serum urea, and brain natriuretic peptide were significantly associated with mortality. The incidence of peritonitis and catheter dysfunction was 0.053 (95% CI 0.014-0.093) and 0.084 (95% CI 0.034-0.133), respectively. The data suggest that PD is a safe, efficient, and well tolerated therapeutic tool for patients with refractory chronic HF and CKD.

Chronic kidney disease and congestive heart failure management: cardionephrologist's role

Kidney is mainly involved in fluid and electrolytes homeostasis, as well as in toxins knockout. Kidney function seems to be strictly related to heart and cardiovascular asset and ‘cardiorenal syndrome’ is now used to identify clinical correlation between heart and kidney disease. Chronic heart failure (CHF) represent first cause of hospitalization in western countries; CHF patients often present with mild to severe chronic kidney disease (CKD). Many physiological and pathophysiological pathways are postulated to explain how CKD can affect CHF prognosis and vice-versa. cGMP and NO - cGMP axis could be involved in pathogenesis of CHF in CKD patients together with natriuretic peptides (ANP and BNP) and phosphodiesterases control. Patients with CHF need to be treated for their chronic volume overload. First choice therapy is undoubtedly diuretic therapy, often with association between different kinds of drugs (such as thiazides and loop diuretics). Ultrafiltration excorporeal treatments are usually indicated in those patients not responding to massive diuretic treatments and they are often employed as complementary treatment in patients with refractory CHF.&nbsp; (Cardionephrology)

Heart failure patients selection for cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is an established treatment for refractory chronic heart failure (CHF) patients with ventricular dyssynchrony. The patient selection for this therapy remains the basis for response improvement. Various parameters, methods and technology for identification of appropriate patient are under research. The influences of age and gender, disease progress stage such as mild and late stage CHF including right ventricular dysfunction, dyssynchrony and scar identified by imaging techniques like echocardiography, magnetic resonance and nuclear imaging, and atrial fibrillation on CRT benefits were respectively discussed. This review summarizes the current advancement in these areas.

112 Levosimedan improves hemodynamics functions without sympathetic activation in severe heart failure patients: direct evidence from sympathetic neural recording

Levosimendan is a new inodilatory agent with calcium sensitizing activity. A major concern regarding the use of inotropic agent in heart failure is their effect on the sympathetic tone. This effect could explain increase in short term mortality with other inotropes. In this setting, the aim of our study was to assess the effect of levosimendan on sympathetic tone measured directly by microneurography. In a group of acute decompensated heart failure patients, we assessed cardiac performance by digital plethysmography (Finometer©) measurement. Sympathetic tone was assessed through recording of muscle sympathetic nerve activity by microneurography. Recording were done blindy, for each patient after dobutamine perfusion was stopped (baseline) and 48 hours after levosimendan infusion. Clinical, biological and morphological data were collected. We compared cardiac parameters and sympathetic nerve activity before and after administration of levosimedan. 13 patients with refractory chronic heart failure were recruited (aged 48±3.6 years). Systolic blood pressure and rate pressure product (mmHg × Beat/min) decreased significantly after levosimendan infusion (p<0.05). Cardiac output and stroke volume assessed by Finometer were significantly increased after levosimendan infusion (p<0.05). A significant decrease of muscle sympathetic nerve activity is observed after levosimendan infusion (p<0.01). Levosimendan cause a significant reduction of plasma brain natriuretic preptide (BNP) after the initiation of the drug (p<0.01). Levosimendan induced improvement of cardiac performance is associated with a decreased in MSNA. This study show for the first time that levosimendan has no direct detrimental effect on the sympathetic nervous system.

Analysis of the advantages of peritoneal dialysis in the treatment of chronic refractory heart failure

Analysis of the advantages of peritoneal dialysis in the treatment of chronic refractory heart failure

Intermittent inotrope infusion in a patient with duchenne muscular dystrophy and end-stage heart failure

Introduction: Due to improvement of respiratory management, the refractory chronic heart failure gains in importance as cause of death in Duchenne muscular dystrophy.

Cardiac resynchronization therapy increases plasma levels of the endogenous inotrope apelin

Cardiac resynchronization therapy (CRT) has been introduced to treat drug refractory chronic heart failure (CHF). Apelin, the endogenous ligand of the APJ receptor, is under evaluation for its potential role in human CHF pathophysiology. This study aims to assess whether biventricular pacing affects plasma apelin levels in patients with severe CHF. Fourteen patients (9 men, 5 women, mean age 68+/-13 years) undergoing biventricular pace-maker/ICD implantation were studied. Patients underwent baseline clinical and echocardiographic evaluation, and assessment of plasma apelin and NT-proBNP levels. The evaluation was repeated 48 h and 9+/-2 months after device implantation to assess the acute and chronic effects of CRT on apelin and NT-proBNP levels. Eight healthy age- and sex-matched subjects served as controls. In CHF patients, baseline apelin levels were reduced and NT-proBNP increased compared to control subjects (apelin: 0.47+/-0.2 vs. 0.97+/-0.3 ng/mL, p<0.001; NT-proBNP: 2007+/-114 vs. 229+/-72 pmol/L, p<0.001). Short-term evaluation did not reveal any effect of CRT on apelin or NT-proBNP levels. By contrast, at 9+/-2 months follow-up, CRT responders showed left ventricular reverse remodelling and an increase in ejection fraction, together with a significant increase in plasma apelin levels (0.99+/-0.1 vs. 0.47+/-0.2 ng/mL, p<0.001) and decrease in NT-proBNP (938+/-591 vs. 2007+/-114 pmol/L, p<0.05). Long-term CRT increases plasma levels of the endogenous inotrope apelin in patients with CHF.

Short-term effect of cardiac resynchronization therapy in patients with ischaemic or nonischaemic cardiomyopathy

Patients with heart failure were candidates for cardiac resynchronization therapy (CRT) regardless of underlying aetiology. This study observed the effect of CRT in patients with ischaemic or nonischaemic cardiomyopathy. One hundred and forty-two patients with refractory chronic heart failure and left bundle branch block received cardiac resynchronization therapy, 91 men and 51 women, average age 60 years. Left ventricular ejection fraction (LVEF) was severely depressed (mean 29%), left ventricular end diastolic diameter (LVEDD) enlarged (mean 72 mm) and QRS width was lengthened (mean 147 ms). Ninety-eight had nonischaemic cardiomyopathy and 44 had ischaemic cardiomyopathy. After cardiac resynchronization therapy, the heart function was significantly improved. The mean LVEF increased from 29% to 36% after pacing. In patients with nonischaemic cardiomyopathy, the LVEF was improved from 28% to 37%, and in patients with ischaemic cardiomyopathy, the LVEF was improved from 30% to 36%. No significant difference of the improvement was found between the two groups (P > 0.05). Cardiac resynchronization therapy could significantly improve cardiac function in patients with chronic heart failure regardless of the underlying heart disease.

Effect of Intracoronary Transplantation of Autologous Bone Marrow-Derived Mononuclear Cells on Outcomes of Patients With Refractory Chronic Heart Failure Secondary to Ischemic Cardiomyopathy

Recent studies have indicated that stem cell implantation increases cardiac function by repairing damaged myocardium. We investigated whether intracoronary transplantation of autologous bone marrow-derived mononuclear cells (BMMCs) confers beneficial effects in patients with refractory chronic heart failure. Twenty-eight patients received standard heart failure medication and BMMC transplantation (BMMC treatment) or standard medication only (controls). BMMCs were harvested from each patient. Clinical manifestations, biochemical assays, rhythm studies, echocardiograms, and positron emission tomograms were recorded. Fourteen patients with cell grafting had symptomatic relief of heart failure within 3 days. Left ventricular ejection fraction increased by 9.2% and 10.5% at 1 week and 3 months after the procedure, respectively, versus baseline (p < 0.01 for the 2 comparisons). Left ventricular end-systolic volume decreased by 30.7% after 3 months (p < 0.01). Brain natriuretic peptide levels at days 3 and 7 after cell infusion significantly decreased by 69.2% and 70.4%, respectively, whereas atrial natriuretic peptide levels increased by 30.1% at day 7. Positron emission tomographic analysis showed a significant increase in cell viability of 10.3% in the infarcted zone. No patient died in the BMMC-treated group at 6-month follow-up. In contrast, heart failure did not improve in any control patient. Left ventricular ejection fraction decreased by 7.2% after 3 months. Two control patients died from heart failure within 6 months. In conclusion, this is the first demonstration in humans that intracoronary BMMC transplantation is a feasible and safe therapeutic strategy to decrease symptoms, increase cardiac function, and possibly prolong life in patients with end-stage heart failure refractory to standard medical therapy.

Cardiac resynchronisation therapy: an option for inotrope-supported patients with end-stage heart failure?

Patients with refractory heart failure requiring inotropic support have a very poor prognosis. Cardiac resynchronization therapy (CRT) offers symptomatic and possibly a survival benefit for patients with stable chronic heart failure (CHF) and a prolonged QRS, but its role in the management of end-stage heart failure requiring inotropic support has not been evaluated. We performed a retrospective observational study of patients undergoing CRT at our institution. We identified 10 patients who required inotropic support for refractory CHF and who underwent CRT while on intravenous inotropic agents. Patients had been in hospital for 30+/-29 days and had received inotropic support for 11+/-6 days prior to CRT. All patients were weaned from inotropic support (2+/-2 days post-CRT) and all patients survived to hospital discharge (12+/-13 days post-CRT). Furosemide dose fell from 160+/-38 mg on admission to 108+/-53 mg on discharge (p<0.01). Serum creatinine fell from 192+/-34 micromol/l prior to CRT to 160+/-37 micromol/l on discharge (p<0.05). Serum sodium was 131+/-4 mmol/l prior to CRT and remained low at 132+/-5 mmol/l on discharge. At short-term follow up (mean 47 days), all patients were alive; mean furosemide dose was 130+/-53 mg (p=0.056 versus pre-CRT). Serum creatinine was 157+/-36 micromol/l and serum sodium had increased to 138+/-6 mmol/l (p<0.05 and p<0.01, respectively, versus pre-CRT). CRT may offer a new therapeutic option for inotrope-supported CHF patients with a prolonged QRS.

Progrès diagnostiques et thérapeutiques: Maladie veineuse thrombo-embolique, insuffisance cardiaque, produits de contraste

MODALITIES FOR THE DIAGNOSIS OF VENOUS THROMBOEMBOLISM: Currently rely on the confrontation of the initial clinical data and the results of D-dimer measurements, a venous Doppler, although reliable, is not a first-line exploration. REGARDING TREATMENT: Indications for thrombolysis are currently limited to massive pulmonary oedema with shock. Alteplase added to heparin improves the progression of severe embolism; it spares the patients from heavy interventions of resuscitation but the mortality remains the same. Concerning anticoagulant treatments, prolonged antivitamin K at classical doses is more effective than low doses and for limited duration if phlebitis is an idiopathic one. FOR HEART FAILURE WITH PRESERVED EJECTION FRACTION: Treatment of these heart failures, formerly know as 'diastolic' is similar to that of the acute phase of systolic heart failure. However, care should be taken with vasodilatators. CONCERNING HEART FAILURE IN GENERAL: The brain natriuretic peptide (BNP) represents a remarkable progress for the aetiological diagnosis of dyspnoea (inferior to 80 pg/ml in the case of pulmonary origin, superior to 300 pg/ml in the case of cardiac origin or severe pulmonary embolism). Regarding treatment, for acute heart failure, it is still the association of nitrates and diuretics, with oxygen therapy and eventually inotropics. Beta-blockers, which have revolutionized the treatment of chronic heart failure, must be maintained whenever possible in the case of the onset of acute pulmonary oedema. Multisite pacing is increasingly used in refractory chronic heart failure. Implantable defibrillation has become common practice. Non-invasive ventilation (Bi or C-PAP) is interesting in acute cardiogenic pulmonary oedema. THE PREVENTIVE ROLE OF N ACETYL-CYSTEINE: N acetyl cysteine reduces the incidence of nephropathies induced by the radio contrast products in patients with chronic kidney failure. Combined with hydratation, it must be proposed the day before and on the day of the procedure in any patient with diabetes or kidney failure.