Refractory Congestive Heart Failure Research Articles

Rationale and design of PURE, a randomized controlled trial to evaluate Peritoneal Ultrafiltration with PolyCore™ in Refractory Congestive Heart Failure.

Peritoneal Ultrafiltration (PUF) has been proposed as an additional therapeutic option for Refractory Congestive Heart Failure (RCHF) patients. Despite promising observational studies and/or case report results, limited clinical trials data exist, and so far, PUF solutions remain only indicated for chronic kidney diseases (CKD). In this article, we describe a multicenter, randomized, controlled, unblinded, adaptive design clinical trial, about to start, investigating the effects of PolyCore™, an innovative PUF solution, in the treatment of RCHF patients. The Peritoneal Ultrafiltration in Cardiorenal Syndrome (PURE) study is a Phase II, multicenter, randomized, controlled, unblinded, adaptive design clinical trial that aims to evaluate the safety and efficacy of PUF, using PolyCore™ as the investigational solution, in the treatment of RCHF patients who present with prominent right ventricular failure due to afterload mismatch, functional tricuspid regurgitation and enlarged cava vein consequent to intravascular fluid overload. Approximately 84 patients will be randomized 1:1 either to continue with their prescribed guidelines-directed medical therapy or to add the PUF treatment on top of it. The primary objective is to evaluate if PUF treatment has an impact on the composite endpoint of the patient's mortality or worsening of the patient's condition such as hospitalization for cardiovascular causes, increasing the initial daily dose of loop diuretic or worsening of renal function. Statistical analysis for the primary endpoint will be standard survival analysis to estimate the failure rate at month 7 for each group via Kaplan-Meier curves. Sensitivity analysis and various secondary analyses, including a multiple events analysis, will be conducted to evaluate the robustness of the primary endpoint results. Safety will be evaluated for up to 12 months. The PURE Study was designed to evaluate the safety and efficacy of peritoneal ultrafiltration with PolyCore™ on top of guidelines-directed medical therapy in patients with RCHF, assuming a combined clinical endpoint of mortality or worsening patients' condition. If successful, the treatment should allow for an improvement of the RCHF symptoms, decreasing hospitalization rate of patients. gov Identifier: NCT03994874.

#2920 Peritoneal dialysis for volume overload in heart failure: a single-center experience

Abstract Background and Aims While diuretics are considered the first-line therapy to control volume overload in heart failure (HF), diuretic resistance can develop, limiting the effectiveness of pharmacological therapy. Peritoneal dialysis (PD) is a kidney replacement therapy usually implemented in advanced or acute kidney failure. However, it can be used to allow ultrafiltration and volume control in refractory cases, either due to kidney or refractory congestive HF. The aim of this study was to describe a single-center experience and study the clinical outcomes of a population of patients with HF that initiated PD for volume control. Method Retrospective single-center study with patients who started PD for volume control between January 1st 2011 and December 31st 2023, with a follow-up of 12 months after start of dialysis or until technique dropout. Demographic and clinical information regarding comorbidities, characteristics of HF, therapeutic management and markers of volume overload (NT-proBNP and CA-125) was collected. The impact on both therapy management and overload markers after six months of PD was also studied. Results Nineteen patients were included in this study, 78.9% of male gender and with a mean age of 63.4 ± 17.2 years. Comorbidities included diabetes in 63.2%, hypertension in 73.7%, coronary arterial disease in 57.8% and peripheral arterial disease in 26.3%. The NYHA (New York Heart Association) class was III or IV in 12 patients (63.1%), with an average left ventricle ejection fraction of 40% ± 14.1, due to ischemic and/or valvular causes in 73.7%. PD vintage was 12 months (IQR 0), with a median glomerular filtration rate (GFR) at the start of peritoneal dialysis of 15 ml/min (IQR 11) while nine patients (47.3%) started with a GFR above 15 mL/min. There was an increase in the number of patients being treated with renin-angiotensin-aldosterone system inhibitors, sodium-glucose co-transporter-2 inhibitors and mineralocorticoids receptor antagonists at six months. Outcomes reported low numbers of major adverse cardiac events, episodes of peritonitis and infection of the peritoneal catheter outer orifice. The number of hospitalizations due to HF was also significantly lower after start of PD (p-value = 0.044). There was a decrease in serum NT-proBNP levels after six months of therapy (p-value = 0.571), with a statistically significant decrease in CA-125 (p-value < 0.001). There was only one reported death during follow-up. Conclusion While PD has classically been viewed only as a kidney replacement therapy, it can also be considered a viable option for refractory volume overload associated with HF. Results suggest an optimization of HF guideline-directed therapy and a decreased number of hospitalizations, with consequent better management of the disease and improved quality of life. There was no negative impact associated with the implementation of PD in this population, with the decrease in CA-125 serum levels also suggesting an overall decrease of volume overload with this technique.

Stiff left atrial syndrome with pulmonary veins occlusion after percutaneous radiofrequency ablation: a life-long complication that can lead to heart transplantation

BackgroundStiff left atrial syndrome (SLAS) and pulmonary vein (PV) occlusion are rare yet potentially major life-long complications after radiofrequency ablation for atrial fibrillation. While mostly controlled by medical management, SLAS can progress to refractory congestive heart failure. Treatment of PV stenosis and occlusion remains a challenging problem with ongoing risk for recurrence regardless of techniques employed. Herein we present the case of a now 51-year-old male with acquired PV occlusion and SLAS who, over the course of eleven years, despite multiple interventions, ultimately required heart transplantation.Case presentationAfter undergoing three radiofrequency catheter procedures for paroxysmal atrial fibrillation (AF), a hybrid ablation was planned due to reappearance of symptomatic AF. Preoperative echocardiography and chest computed tomography (CT) revealed an occlusion of both left PVs. Furthermore, left atrial dysfunction, high pulmonary artery and pulmonary wedge pressures were diagnosed as well as an important reduction of the left atrial volume. The diagnosis of stiff left atrial syndrome was made. Primary surgical repair of the left-sided PVs was performed using a pericardial patch as a tubular neo-vein, combined with cryoablation in the left and right atrium to treat the patient’s arrhythmia. Initial results were favorable, however, after two years the patient experienced progressive restenosis with hemoptysis. Therefore, stenting of the common left PV was performed. Over the years, progressive right heart failure with severe tricuspid regurgitation developed, despite maximal medical therapy, which led to the need for heart transplantation.ConclusionThe impact of PV occlusion and SLAS after percutaneous radiofrequency ablation can be lifelong and devastating for the clinical course of the patient. Since the presence of a small left atrium could be an important predictor for SLAS in case of redo ablation, preprocedural imaging should guide the operator to an algorithm of a decision-making containing lesion set, energy source, and safety of re-ablation.

Peritoneal and Urinary Sodium Removal in Refractory Congestive Heart Failure Patients Included in an Ambulatory Peritoneal Dialysis Program: Valuable for Monitoring the Course of the Disease

Introduction: Spot urinary sodium emerged as a useful parameter for assessing decongestion in patients with congestive heart failure (CHF). Growing evidence endorses the therapeutic role of continuous ambulatory peritoneal dialysis (CAPD) in patients with refractory CHF and kidney disease. We aimed to examine the long-term trajectory of urinary, peritoneal, and total (urinary plus peritoneal) sodium removal in a cohort of patients with refractory CHF enrolled in a CAPD program. Additionally, we explored whether sodium removal was associated with the risk of long-term mortality and episodes of worsening heart failure (WHF). Methods: We included 66 ambulatory patients with refractory CHF enrolled in a CAPD program in a single teaching center. 24-h peritoneal, urinary, and total sodium elimination were analyzed at baseline and after CAPD initiation. Its trajectories over time were calculated using joint modeling of longitudinal and survival data. Within the framework of joint frailty models for recurrent and terminal events, we estimated its prognostic effect on recurrent episodes of WHF. Results: At the time of enrollment, the mean age and estimated glomerular filtration rate were 72.8 ± 8.4 years and 28.5 ± 14.3 mL/min/1.73 m2, respectively. The median urinary sodium at baseline was 2.34 g/day (1.40–3.55). At a median (p25%–p75%) follow-up of 2.93 (1.93–3.72) years, we registered 0.28 deaths and 0.24 episodes of WHF per 1 person-year. Compared to baseline (urinary), CAPD led to increased sodium excretion (urinary plus dialyzed) since the first follow-up visit (p < 0.001). Over the follow-up, repeated measurements of total sodium removal were associated with a lower risk of death and episodes of WHF. Conclusions: CAPD increased sodium removal in patients with refractory CHF. Elevated sodium removal identified those patients with a lower risk of death and episodes of WHF.

Peritoneal dialysis in patients with refractory congestive heart failure

Chronic heart failure is a growing problem. Despite progress in its management, many patients become refractory to therapies including diuretic resistance, major congestion, and worsening renal function. The only alternative to get rid of excess water and sodium is ultrafiltration, which can be achieved via hemodialysis or peritoneal dialysis (PD). The majority of studies have shown multiple benefits of PD as an improvement in functional class, a reduction in hospitalization leading to increased quality of life, and even a reduction in mortality. Being a home dialysis technique, it is more favorably accepted by patients. It remains necessary to confirm these potential positive outcomes and to identify patients who would benefit the most from this treatment in the era of new therapies available to date.

The Peritoneal Membrane—A Potential Mediator of Fibrosis and Inflammation among Heart Failure Patients on Peritoneal Dialysis

Peritoneal dialysis is a feasible, cost-effective, home-based treatment of renal replacement therapy, based on the dialytic properties of the peritoneal membrane. As compared with hemodialysis, peritoneal dialysis is cheaper, survival rate is similar, residual kidney function is better preserved, fluid and solutes are removed more gradually and continuously leading to minimal impact on hemodynamics, and risks related to a vascular access are avoided. Those features of peritoneal dialysis are useful to treat refractory congestive heart failure patients with fluid overload. It was shown that in such patients, peritoneal dialysis improves functional status and quality of life, reduces hospitalization rate, and may decrease mortality rate. High levels of serum proinflammatory cytokines and fibrosis markers, among other factors, play an important part in congestive heart failure pathogenesis and progression. We demonstrated that those levels decreased following peritoneal dialysis treatment in refractory congestive heart failure patients. The exact mechanism of beneficial effect of peritoneal dialysis in refractory congestive heart failure is currently unknown. Maintenance of fluid balance, leading to resetting of neurohumoral activation towards a more physiological condition, reduced remodeling due to the decrease in mechanical pressure on the heart, decreased inflammatory cytokine levels and oxidative stress, and a potential impact on uremic toxins could play a role in this regard. In this paper, we describe the unique characteristics of the peritoneal membrane, principals of peritoneal dialysis and its role in heart failure patients.

Regular at-home abdominal paracentesis via Tenckhoff catheter in patients with refractory congestive heart failure.

Peritoneal dialysis (PD) is increasingly used for the long-term management of refractory congestive heart failure (CHF). Patients with severe CHF and ascites were treated with regular at-home abdominal paracentesis via Tenckhoff catheter. We investigated the outcome of those patients, aiming to identify potential prognostic factors for longer survival. Patients with refractory CHF referred by cardiologists to the PD unit from years 2009 to 2019 and treated with regular at-home abdominal paracentesis via Tenckhoff catheter without peritoneal exchanges, were enrolled into this prospective observational study. From the total of 69 refractory CHF patients treated with PD, 18 (26%) were managed with regular at-home abdominal paracentesis via Tenckhoff catheter and improved without the need for peritoneal exchanges for fluid removal (no peripheral oedema or pulmonary congestion) or for solutes removal. Median survival of severe CHF patients treated with abdominal paracentesis was 13.5months (0-34months). Long-term survivors demonstrated significant improvement in the New York Heart Association (NYHA) functional class, improvement in kidney function and decrease in serum C-reactive protein (CRP) and Brain natriuretic peptide (BNP) compared with their baseline status. A subgroup of patients with shorter survival were more likely to have evidence of liver cirrhosis and significantly lower serum sodium compared with patients with longer survival. Refractory CHF patients with massive ascites could be successfully treated with regular at-home abdominal paracentesis via Tenckhoff catheter. This treatment provides a useful alternative to periodical percutaneous paracentesis on as-needed basis.

Transvalvular pulmonic stent angioplasty: procedural outcomes and complications in 15 dogs with pulmonic stenosis

IntroductionBalloon valvuloplasty is the treatment of choice for dogs with severe type A pulmonic stenosis (PS), but less successful for dogs with annular hypoplasia and unsuitable for supravalvular stenosis or cases with a circumpulmonary coronary malformation. We report outcomes and complications of the first 15 consecutive transvalvular pulmonic stent angioplasty procedures performed by a single center in dogs with PS. AnimalsFifteen dogs with naturally occurring PS were included in the study. Materials and methodsDogs underwent echocardiography before and four weeks after the procedure. Transvenous approaches were used to deploy a pre-mounted, balloon-expandable metallic stent in all cases. ResultsOf 15 dogs, all had annular hypoplasia, and in addition, supravalvular stenosis was diagnosed in 11 of 15 dogs, and three had R2A coronary malformation. All dogs survived to discharge. One dog died less than four weeks postoperatively (non-cardiac), but 14 of 15 dogs were re-examined at four weeks. Severity reduced in all cases; median pressure gradient reduced from 137 mmHg (range 81–202 mmHg) to 83 mmHg (range 31–155 mmHg). Clinical signs improved in all cases, and hematocrit reduced in all dogs with erythrocytosis. The median follow-up time was 280 days (range 95–896 days). Over one-year follow-up was available in six of fifteen dogs. Two dogs died because of refractory right-sided congestive heart failure signs: one at 10 months and one at 22 months postoperatively. ConclusionsTransvalvular pulmonic stent angioplasty technique was associated with an improvement in clinical signs and reduction in stenosis severity for all dogs in this population, including cases with supravalvular PS or circumpulmonary coronary malformation.

LEFT VENTRICULAR ANEURYSM AND VENTRICULAR SEPTAL DEFECT FOLLOWING MYOCARDIAL INFARCTION: A DANGEROUS COCKTAIL

An ischemic ventricular septal defect (VSD) is a lethal complication of myocardial infarction (MI), commonly from 24 hours to up to 5 days of presentation with AMI. Despite the improvement of surgical techniques, the mortality is still very high with poor prognosis. Left ventricular aneurysm (LVA) may also be a fatal mechanical complication of MI but rarely occurs in the posterior or inferior portion of the interventricular septum. Concomitant AMI mechanical complications in the same patient are less than infrequent with poor prognosis, particularly with late hospital arrival. We present an unusual case of post-myocardial infarction ventricular septal rupture (PI-VSR) combined with left ventricular inferior/inferoseptal aneurysm that was managed surgically. The aim of this article is to make clinician alerted in case of mechanical complication, especially when post-MI patients become hemodynamically unstable with refractory congestive heart failure.

Peritoneal dialysis in dogs and cats

Dialysis represents the separation process of a colloidal dispersion substance from molecular dispersion particles, based on the property of certain membranes to retain only colloidal particles. In veterinary medicine, the most common use for peritoneal dialysis is the therapy of acute kidney injury, although it can be employed for removing dialyzable toxins and treating pancreatitis, electrolyte disorders and acid-base imbalances, refractory congestive heart failure and metabolic congenital disorders. Peritoneal dialysis is contraindicated in patients with peritoneal adhesions, fibrosis or abdominal malignant tumours. The ideal catheter for dialysis allows for an adequate administration and evacuation of the dialysate, it determines minimum subcutaneous losses, it minimizes infection both in the peritoneal cavity and in the subcutaneous tissue. The placement method for peritoneal dialysis catheters depends on the catheter itself, on the patient and on the approximate duration of the dialysis. In cases of extreme emergency, when the peritoneal dialysis should not be used more than 72 hours, the placement of a short-term catheter is justified. The peritoneal dialysis system is placed immediately after the peritoneal dialysis catheter is inserted and attached to a closed collection system, being carefully prepped in place with dry sterile dressings. The ideal peritoneal dialysis solution should achieve the low absorption clearance of osmotic agents, provide missing or insufficient electrolytes and nutrients, correct acid-base imbalances, inhibit growth of microorganisms, and be inert with regard to the peritoneum. When initiating peritoneal dialysis in acute kidney injury, the main goal is not to immediately normalize uraemia. The initial objectives should be to normalize the hemodynamic status of the patient and the acid-base and electrolyte imbalances, as well as to reduce uraemia to a BUN of 60-100 mg/dl and to reach a creatinine of 4.0-6.0 mg/dl in 24-48 hours. Complications of peritoneal dialysis are common, but they can be easily managed if discovered or addressed in due time. The most common complications are: peritoneal catheter obstruction, electrolyte imbalances, hypoalbuminemia and bacterial peritonitis.

Correction of serum chloride concentration in dogs with congestive heart failure.

BackgroundHypochloremia associated with congestive heart failure (CHF) in dogs is likely multifactorial. Loop diuretics cause 1:2 sodium [Na+]:chloride [Cl−] loss, whereas water retention causes a 1:1 [Na+]:[Cl−] dilution. Mathematical [Cl−] correction separates these effects on [Cl−].HypothesisWe hypothesized that corrected [Cl−] (c[Cl−]) would not differ from measured [Cl−] (m[Cl−]) in dogs with controlled CHF because of loop diuretics, and dogs with refractory CHF would have higher c[Cl−] than m[Cl−], indicating relative water excess.AnimalsSeventy‐one client‐owned dogs with acquired heart disease, without CHF (NO‐CHF), 76 with Stage C CHF and 24 with Stage D CHF.MethodsClinicopathological data from a previous study were retrospectively analyzed. Corrected [Cl−], m[Cl−], and differences were compared among NO‐CHF, Stage C CHF, and Stage D CHF, using the formula: c[Cl−] = (mid‐reference range [Na+]/measured [Na+]) × m[Cl−].ResultsCorrected [Cl−] and m[Cl−] were lower in Stage D vs Stage C and NO‐CHF (all P < .0001). The c[Cl−] was higher than m[Cl−] in Stage D (P < .0001) but not Stage C or NO‐CHF. Median difference between c[Cl−] and m[Cl−] was higher for Stage D vs Stage C (P = .0003). No hypochloremic Stage D dogs had normal c[Cl−], but 11/24 had [Cl−] that was increased by >2 mmol/L.Conclusions and Clinical ImportanceSerum [Cl−] increased after mathematical correction in Stage D CHF dogs but not in Stage C and NO‐CHF dogs. Although c[Cl−] was higher than m[Cl−] in Stage D dogs supportive of relative water excess, hypochloremia persisted, consistent with concurrent loop diuretic effects on electrolytes. Future study correlating c[Cl−] to antidiuretic hormone concentrations is warranted.

Congestive heart failure treated with peritoneal dialysis or hemodialysis: Typical patient profile and outcomes in real-world setting.

Peritoneal dialysis (PD) is increasingly used for the long-term management of hypervolemic refractory congestive heart failure (CHF) patients, in particular when complicated by renal insufficiency. While PD has many advantages over hemodialysis (HD) in those patients, there is a controversy concerning survival superiority of PD compared with HD in this population. The aim of the study was to define typical patient profile and to compare outcomes of patients with CHF and renal failure treated with HD or PD. This retrospective cohort study enrolled CHF patients treated with chronic PD or HD between the years 2009-2018. Information at dialysis initiation included age, gender, body weight, blood pressure, cause of renal disease, comorbidities, hospitalisations, echocardiographic and laboratory parameters. Survival was compared between PD and HD patients using a Kaplan-Meier model and Cox regression analysis. CHF patients treated with PD had significantly higher eGFR and lower systolic blood pressure compared with HD treated patients. Median survival time was 13.32 (7.08, 23.28) months in the PD group and 19.68 (9.48, 39.24) months in the HD group, P=.013. After adjustment for confounders the mortality risk amongst PD and HD patients was not significantly different: adjusted HR for death in PD vs HD patients was 1.44, P=.35 for 1- year and 1.69, P=.10 for 2-year mortality. Number of hospitalisations was similar in both groups. CHF patient profile was different in PD and HD. Two modalities were equally effective in the treatment of patients with CHF and renal failure considering different patient characteristics.

Pseudo-loss of left ventricular capture due to interventricular crosstalk.

An 82-year-old man was admitted to our clinic for evaluation of chronic heart failure (CHF) often punctuated by acute exacerbations. The patient had undergone placement of a biventricular implantable cardioverter-defibrillator (ICD) capable of cardiac resynchronization therapy (CRT-D; Unify Quadra 3251-40Q; St. Jude Medical, St Paul, MN) six years ago in a tertiary centre due to nonischemic cardiomyopathy, left bundle branch block (LBBB) QRS pattern of QRS duration 250 ms and drug refractory congestive heart failure with left ventricular ejection fraction (LVEF) of 25%. St. Jude Medical leads had been implanted using an Durata™ 7120Q passive right ventricular (RV) lead in the apex, an Tendril™ 1888 bipolar screw-in lead in the right atrium (RA) and an Quartet™ 1458Q quadripolar LV lead in an anterolateral coronary vein. Follow-up in-person outpatient visits occurred regularly at another hospital. Overall, the non-pacemaker dependent patient had unchanged NYHA functional class III-IV symptomatology and similar LVEF. This article is protected by copyright. All rights reserved.

Repair of isolated atrial septal defect in infants less than 12 months improves symptoms of chronic lung disease or shunt-related pulmonary hypertension.

Infants with isolated atrial septal defects are usually minimally symptomatic, and repair is typically performed after infancy. Early repair may be considered if there is high pulmonary blood flow and reduced respiratory reserve or early signs of pulmonary hypertension. Our aim was to review the characteristics and outcomes of a cohort of patients who underwent infant repair at our institute. The study included 56 infants (28 female, 19 trisomy 21) with isolated atrial septal defect (age: 8 months (1.5-12), weight: 6 kg (2.8-7.5), echo Qp/Qs: 1.9 ± 0.1) who underwent surgical closure (20 fenestrated). Three groups were identified: 1) chronic lung disease and pulmonary hypertension (group A: n = 28%); 2) acutely unwell infants with pulmonary hypertension but no chronic lung disease (group B: n = 20, 36%); and 3) infants with refractory congestive heart failure without either pulmonary hypertension or chronic lung disease (group C: n = 9, 16%). Post-operatively, pulmonary hypertension infants (47/56) showed improvement in tricuspid annular plane systolic excursion z-score (p < 0.001) and right ventricular systolic/diastolic duration ratio (p < 0.05). All ventilator (14.3%) or oxygen-dependent (31.6%) infants could be weaned within 2 weeks after repair. One year later, weight z-score increased in all patients and by +1 in group A, +1.3 in group B and +2 in group C. Over a median follow-up of 1.4 years, three patients died, four patients continued to have pulmonary hypertension evidence and two remained on targeted pulmonary hypertension therapy. Atrial septal defect repair within the first year may improve the clinical status and growth in infants with early signs of pulmonary hypertension or those requiring respiratory support and facilitate respiratory management.

Central conversion from peripheral extracorporeal life support for patients with refractory congestive heart failure.

Conversion from peripheral extracorporeal life support (ECLS) to the central one can improve and stabilize hemodynamics in patients with refractory congestive heart failure-related multiorgan failure, whereas indication and selection of the type of the central ECLS have not been fully established. Institutional outcome of the conversion therapy was herein reviewed to verify indication and selection of three types of central ECLS. This study enrolled an institutional consecutive surgical series of 24 patients with refractory congestive heart failure under peripheral ECLS, related to fulminant myocarditis (n = 15), dilated cardiomyopathy (n = 5), or acute myocardial infarction (n = 4). They were converted to central Y-extracorporeal membrane oxygenation (ECMO, n = 6), extracorporeal ventricular assist device (EC-VAD, n = 12), or pump catheter (n = 6), dependent upon the degree of multiorgan failure. Despite the different degree of multiorgan failure prior to the conversion, improvement in end-organ perfusion and reduction in right atrial and pulmonary artery pressure were promptly achieved regardless of the type of the central ECLS. There were five in-hospital mortalities (21%) during the central ECLS, whereas mechanical support was weaned-off in 11 cases (46%) and durable LVAD was subsequently implanted for bridge to transplantation in eight cases (33%). Conversion from the peripheral ECLS to the central ones, such as central Y-ECMO, EC-VAD or pump catheter, promptly established a sufficient support with heart and lung unloading in patients with refractory congestive heart failure.

Hemochromatosis related refractory congestive heart failure associated with autoimmune hemolytic anemia in a Young Chinese Female: A case report

Hereditary hemochromatosis (HH) is a hereditary disease associated with iron overload in multiple organs. Autoimmune hemolytic anemia is an autoimmune disease where extravascular hemolysis takes place mainly in spleen and may be associated with secondary hemochromatosis. HH is common among northern European people and very rare in China. This unique case is first time ever reported in China describing a 23-year-old Chinese woman with a history of splenectomy at age 13 due to autoimmune hemolytic anemia, secondary amenorrhea at age 19 which had not been investigated before and diabetes mellitus at age 22 presenting with congestive heart failure and hepatomegaly. Her chronic autoimmune hemolytic anemia alone could not sufficiently justify secondary hemochromatosis and iron overload syndrome due to which possibility of HH (probably Juvenile Hemochromatosis) was considered mainly on the basis of increased serum iron and transferrin saturation more than 45%, iron deposits in Magnetic Resonance Imaging (MRI) of liver, heart and pituitary gland, and clinical manifestations. However, secondary hemochromatosis couldn’t be excluded as patient denied taking genetic sequencing test for HH. When genetic screening is not feasible or readily available, we encourage that in autoimmune hemolytic anemia cases, iron metabolism measurements should be performed routinely which might help in early recognition of HH or secondary hemochromatosis even before excessive iron overload so that phlebotomy or iron chelators can be used as early as possible to prevent possible organ damage. Due to rarity of disease there is less data available regarding the cardiac manifestations and management, we also tried to focus on treatment especially congestive heart failure, arrhythmia which is the presenting manifestation in young adults in hemochromatosis. Therefore, main aim of this case report is to support the pre-existing evidences for diagnosing Juvenile Hemochromatosis (JH) on the basis of transferrin saturation and serum ferritin levels, clinical manifestations and radiography of target organs.

Challenging Transcatheter Treatment of a “Complex” Refractory Congestive Heart Failure

A 61-year-old man with a history of postischemic dilated cardiomyopathy was referred in advanced congestive heart failure to our department (Department of Cardiology). He had a history of acute inferolateral myocardial infarction complicated by left ventricular (LV) aneurysm treated elsewhere by coronary artery bypass grafts, aneurysm resection, and automatic implantable cardioverter defibrillator implantation a few years before. At the time of admission, he was in functional New York Heart Association class III-IV with signs and symptoms of congestive heart failure and low cardiac output.

Role of electrolyte concentrations and renin-angiotensin-aldosterone activation in the staging of canine heart disease.

BackgroundRefractory congestive heart failure (CHF) and associated diuretic resistance are not well defined.ObjectivesTo characterize renal function, electrolyte concentrations, indices of diuretic efficacy, and renin‐angiotensin‐aldosterone system (RAAS) activation in dogs with naturally occurring heart disease (HD) in American College of Veterinary Internal Medicine stages B1, B2, C, and D and to determine their usefulness in defining HD stages.AnimalsGroup 1:149 dogs with HD stages B1, B2, C, and D. Group 2:22 dogs with HD stages C and D.MethodsGroup 1: Renal parameters, serum and urine electrolyte and diuretic concentrations, and urine aldosterone concentrations were measured. Medication dosages and measured variables were compared among stages. Correlation of furosemide dosages to serum concentrations was explored. Group 2: Angiotensin‐converting enzyme activity and RAAS components were measured and compared among CHF stages.ResultsSerum chloride concentration was the best differentiator of HD stage. Furosemide PO dosages (≤6 mg/kg/day) were weakly correlated with serum furosemide concentrations, whereas higher dosages were not significantly correlated. Angiotensin‐converting enzyme inhibitor dosage and RAAS inhibition were greater in stage D, compared to stage C dogs.Conclusions and Clinical ImportanceHypochloremia is a useful marker for stage D HD in dogs. Poor furosemide dosage correlation to serum concentration may indicate variable and poor absorption, especially at higher dosages, advanced disease, or both. A small number of stage D dogs met proposed criteria for diuretic resistance. Greater RAAS inhibition in stage D versus stage C indicates effectiveness of RAAS‐suppressive treatments in this group of dogs with refractory CHF.

Effect of Peritoneal Dialysis on Serum Fibrosis Biomarkers in Patients with Refractory Congestive Heart Failure.

Background: Cardiac collagen remodeling is important in the progression of heart failure. Estimation of cardiac collagen turnover by serum levels of serological markers is used for monitoring cardiac tissue repair and fibrosis. Peritoneal dialysis (PD) is used for the long-term management of refractory congestive heart failure (CHF). In this study, we investigated the effect of PD treatment on circulating fibrosis markers levels in patients with refractory CHF and fluid overload. Methods: Twenty-five patients with refractory CHF treated with PD were prospectively enrolled in the study. Circulating fibrosis markers procollagen type III C-peptide (PIIINP), matrix metalloproteinase 2 (MMP-2), and tissue inhibitor of metalloproteinases I (TIMP-1) levels were checked at baseline and after three and six months of treatment. Results: The clinical benefit of PD manifested by improved NYHA functional class and reduced hospitalization rate. Serum brain natriuretic peptide (BNP) levels decreased significantly during the treatment. Serum MMP-2 and TIMP-1 decreased significantly on PD. Circulating PIIINP showed two patterns of change, either decreased or increased following PD treatment. Patients in whom circulating PIIINP decreased had significantly lower baseline serum albumin, lower baseline mean arterial blood pressure, higher serum CRP, and a less significant improvement in hospitalization rate compared to the patients in whom circulating PIIINP increased. Patients in whom all three markers decreased demonstrated a trend to longer survival compared to patients whose markers increased or did not change. Conclusion: In refractory CHF patients PD treatment was associated with a reduction in circulating fibrosis markers.

PERCUTANEOUS USE OF THE ANGIOVAC SYSTEM IN ENDOCARDITIS PATIENTS WHO ARE POOR SURGICAL CANDIDATES

The tricuspid valve is involved in 10-25% of all cases of endocarditis. Antibiotics remain the cornerstone treatment. Surgical intervention is indicated for persistent bacteremia, recurrent embolization despite appropriate antibiotics, large vegetations or refractory congestive heart failure. In