Thomas M. O'Brien

Ultrafiltration in Heart Failure with Preserved Ejection Fraction: Comparison with Systolic Heart Failure Patients

Background—Ultrafiltration (UF) is a widely used technology for inpatient management of acute decompensated heart failure in patients with volume overload. However, the safety and efficacy of UF in patients with heart failure and preserved left ventricular ejection fraction (heart failure with preserved ejection fraction [HFPEF]) need further clarification. We hypothesized that UF could be used in this population with outcomes similar to acute decompensated heart failure patients with low left ventricular ejection fraction (HFLEF). Methods and Results—Prospective evaluation was performed on 2 patient cohorts admitted to a single institution for acute decompensated heart failure and treated with UF: HFLEF (left ventricular ejection fraction ⩽40%; n=87) and HFPEF (left ventricular ejection fraction >40%; n=97). Selected demographic and clinical data were compared, including clinical and serological information, as well as in-hospital and 90-day postdischarge mortality. HFPEF patients were more likely to be women, have higher blood pressures, and less likely to have ischemic heart disease. There were no significant differences in total weight loss (7.7% in HFLEF and 7.0% in HFPEF), electrolyte and renal disturbances, or in-hospital mortality (3.4% in HFLEF and 3.3% in HFPEF) between the 2 groups. Mortality at 90 days tended to be greater in HFLEF (24.1%) than in HFPEF (15.5%). Conclusions—Therapeutic responses in patients with HFPEF meeting current indication for UF are similar to those with HFLEF. Larger studies are warranted to better characterize acute heart failure management with UF in this population.Background— Ultrafiltration (UF) is a widely used technology for inpatient management of acute decompensated heart failure in patients with volume overload. However, the safety and efficacy of UF in patients with heart failure and preserved left ventricular ejection fraction (heart failure with preserved ejection fraction [HFPEF]) need further clarification. We hypothesized that UF could be used in this population with outcomes similar to acute decompensated heart failure patients with low left ventricular ejection fraction (HFLEF). Methods and Results— Prospective evaluation was performed on 2 patient cohorts admitted to a single institution for acute decompensated heart failure and treated with UF: HFLEF (left ventricular ejection fraction ≤40%; n=87) and HFPEF (left ventricular ejection fraction >40%; n=97). Selected demographic and clinical data were compared, including clinical and serological information, as well as in-hospital and 90-day postdischarge mortality. HFPEF patients were more likely to be women, have higher blood pressures, and less likely to have ischemic heart disease. There were no significant differences in total weight loss (7.7% in HFLEF and 7.0% in HFPEF), electrolyte and renal disturbances, or in-hospital mortality (3.4% in HFLEF and 3.3% in HFPEF) between the 2 groups. Mortality at 90 days tended to be greater in HFLEF (24.1%) than in HFPEF (15.5%). Conclusions— Therapeutic responses in patients with HFPEF meeting current indication for UF are similar to those with HFLEF. Larger studies are warranted to better characterize acute heart failure management with UF in this population.

A Pilot Study of Target Weight Guided Treatment in Acute Heart Failure Using Ultrafiltration or Usual Care: Effect on Sodium Removal

Background and Objectives In the Ultrafiltration versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Heart Failure trial, ultrafiltration (UF) removed volume more effectively than usual care (UC). Hypothetically, UF may be superior to UC due to increased sodium (Na) removal and less neurohormonal activation. We compared UF and UC in a randomized pilot trial of target weight guided therapy for acute decompensated heart failure (ADHF). Subjects and Methods Sixteen patients with ADHF were enrolled and target weights established prospectively, prior to randomization to UC or UF. UF patients did not receive diuretics and UC patients were all treated with a continuous furosemide drip. All urine and ultrafiltrate were collected and Na concentrations measured. Results Similar volumes were removed in UC and UF groups (110105 mL and 107415 mL, respectively) and the UF group also produced 45325 mL of urine. Na concentration was 138±6 meq/L in the ultrafiltrate, 85±73 meq/L in the UC groups urine, and 26±23 meq/L in the UF groups urine. Given the relevant associated volumes, total meq of the Na removed was similar (1168 in UC vs. 1216 in UF). The UF group produced isotonic ultrafiltrate and a higher volume of dilute urine than anticipated. Conclusion In a randomized pilot study of target weight guided therapy with UC or UF for ADHF, there were no differences in total volumes or Na removed, and lengths of hospital stays were similar. Isotonic fluid loss by UF was accompanied by the production of very dilute urine.