Tomotaka Ando

Intravenous Salt Supplementation With Low-Dose Furosemide for Treatment of Acute Decompensated Heart Failure

BACKGROUND Theoretically, salt supplementation should promote diuresis through increasing the glomerular filtration rate (GFR) during treatment of acute decompensated heart failure (ADHF) even with low-dose furosemide; however, there is little evidence to support this idea. METHODS AND RESULTS This was a prospective, randomized, open-label, controlled trial that compared the diuretic effectiveness of salt infusion with that of glucose infusion supplemented with low-dose furosemide in 44 consecutive patients with ADHF. Patients were randomly administered 1.7% hypertonic saline solution supplemented with 40 mg furosemide (salt infusion group) or glucose supplemented with 40 mg furosemide (glucose infusion group). Our major end points were 24-hour urinary volume and GFR. Urinary volume was greater in the salt infusion group than in the glucose infusion group (2,701 ± 920 vs 1,777 ± 797 mL; P < .001). There was no significant difference in the estimated GFR at baseline. Creatinine clearance for 24 h was greater in the salt infusion group than in the glucose infusion group (63.5 ± 52.6 vs 39.0 ± 26.3 mL min(-1) 1.73 m(-2); P = .048). CONCLUSIONS Salt supplementation rather than salt restriction evoked favorable diuresis through increasing GFR. The findings support an efficacious novel approach of the treatment of ADHF.

Combination of hypertonic saline and low-dose furosemide is an effective treatment for refractory congestive heart failure with hyponatremia

Hyponatremia often associates with heart failure. Although severe salt restriction is generally recommended in heart failure treatment, it may promote hyponatremia which is a risk factor for increased morbidity and mortality in heart failure patients. Therefore, it is not yet clear whether correction of hyponatremia is an effective treatment in congestive heart failure with hyponatremia. We experienced a successful case of refractory congestive heart failure with hyponatremia treated with hypertonic saline and furosemide. A 45-year-old man, suffering from dilated cardiomyopathy, was admitted to our hospital for heart failure worsening with hyponatremia. We started diuretics therapy without correction of hyponatremia, but his clinical status of heart failure was not improved. Therefore, we additionally started to correct hyponatremia by continuous injection of hypertonic saline. The correction of hyponatremia increased urinary volume dramatically, and improved cardiac output and clinical status of heart failure. This case strongly suggests that combination of hypertonic saline and furosemide could enhance diuretic effect, and improve the clinical status of heart failure in congestive heart failure patients with hyponatremia. <Learning objective: Hyponatremia is a major problem associated with heart failure, but it is not yet clear whether correction of hyponatremia is an effective treatment in patients with congestive heart failure. We experienced a successful case of refractory congestive heart failure with hyponatremia treated with hypertonic saline and low dose furosemide. This case strongly suggests that aggressive correction of hyponatremia can be an effective treatment for refractory congestive heart failure with hyponatremia.>.

Dominant cardiac type of familial amyloidotic polyneuropathy associated with a novel transthyretin variant Thr59Arg

distal predominant tetraparesis and increasing dysphagia, resulting in choking and loss of weight. After treatment with 2 g/kg body weight with IVIg over 5 days, the dysphagia improved. This positive effect diminished after approximately 4 weeks. Over time, stabilization of bulbar dysfunction and slowing of the progressive tetraparesis occurred with a reduced dose of IVIg [1.25 g/kg body weight (60 kg) over 3 days, every 4–5 weeks]. Dysphagia improved dramatically and led to weight gain and subsequent stabilization of body weight. However, limb paresis and disability increased slowly. After nearly 2 years of IVIg, treatment was changed to subcutaneous applications of 3.3 g immunoglobulin (SCIg) 4 times per week to enable more autonomy [0.77 g/kg body weight (68 kg) per month (Gammanorm), with a 16.5% immunoglobulin concentration]. On this regimen swallowing remained stable, and body weight was constant over the next 4 years (Fig. 1). Similarly, grip strength was stable (Fig. 1) despite slowly progressive leg paresis. Herein we have reported the use of SCIg in a patient with IBM. We found that SCIg may be as efficient as IVIg in treating IBM, and response to treatment proved similar to the positive effects of SCIg in other neurological autoimmune diseases. Although weakness of limb muscles persisted, the therapy with SCIg successfully prevented parenteral nutrition and enabled the patient to live as autonomously as possible. The results of the controlled IVIg trials are controversial. A slight amelioration in certain muscles, notably in the pharyngeal muscles, was reported in 2 studies and in 1 case series, indicating that patients with dysphagia in particular may benefit from immunoglobulin treatment. If IVIg shows clinical efficacy, the dose should be tapered to achieve long-lasting stabilization. This case illustrates that a change to SCIg may maintain the therapeutic effect of IVIg over many years and could improve the quality of life in patients who can gain more autonomy through self-administration of SCIg.

Adaptive Servo-Ventilation Treatment Increases Stroke Volume in Stable Systolic Heart Failure Patients With Low Tricuspid Annular Plane Systolic Excursion

We hypothesized that the effects of adaptive servo-ventilation (ASV) therapy were influenced by right-sided heart performance. This study aimed to clarify the interaction between the effects of ASV and right-sided heart performance in patients with stable heart failure (HF) with reduced ejection fraction (HFrEF).Twenty-six stable HF inpatients (left ventricular ejection fraction < 0.45, without moderate to severe mitral regurgitation (MR) were analyzed. Echocardiography was performed before and after 30 minutes of ASV. ASV increased stroke volume index (SVI) in 14 patients (30.0 ± 11.9 to 41.1 ± 16.1 mL/m2) and reduced SVI in 12 patients (36.0 ± 10.1 to 31.9 ± 12.2 mL/m2). Multivariate linear regression analysis revealed that tricuspid annular plane systolic excursion (TAPSE) before ASV was an independent association factor for (SV during ASV - SV before ASV)/LVEDV × 100 (%) (%ΔSV/LVEDV). ROC analysis of TAPSE for %ΔSV/LVEDV > 0 showed that the cut-off point was 16.5 mm. All patients were divided into 2 groups according to the TAPSE value. Although no significant differences were found in the baseline characteristics and blood tests, there were significant differences in tricuspid lateral annular systolic velocity, TAPSE, right atrial area, and right ventricular (RV) area before ASV between patients with TAPSE ≤ 16.5 mm and those with TAPSE > 16.5 mm. Interestingly, ASV reduced RV area and increased TAPSE in patients with TAPSE ≤ 16.5 mm, while it reduced TAPSE in those > 16.5 mm.ASV therapy has the potential to increase SVI in stable HFrEF patients with low TAPSE.

Right Ventricular Enlargement and Renal Function Are Associated With Smooth Introduction of Adaptive Servo-Ventilation Therapy in Chronic Heart Failure Patients

Although adaptive servo-ventilation (ASV) therapy has beneficial effects on chronic heart failure (CHF), a relatively large number of CHF patients cannot undergo ASV therapy due to general discomfort from the mask and/or positive airway pressure. The present study aimed to clarify baseline patient characteristics which are associated with the smooth introduction of ASV treatment in stable CHF inpatients.Thirty-two consecutive heart failure (HF) inpatients were enrolled (left ventricular ejection fraction (LVEF) < 45%, estimated glomerular filtration rate (eGFR) > 10 mL/minute/1.73m2, and apnea-hypopnea index < 30/hour). After the patients were clinically stabilized on optimal therapy, they underwent portable polysomnography and echocardiography, and then received ASV therapy. The patients were divided into two groups: a smooth introduction group (n = 18) and non-smooth introduction group (n = 14). Smooth introduction of ASV treatment was defined as ASV usage for 4 hours and more on the first night. Univariate analysis showed that the smooth introduction group differed significantly from the non-smooth introduction group in age, hemoglobin level, eGFR, HF origin, LVEF, right ventricular (RV) diastolic dimension (RVDd), RV dp/dt, and RV fractional shortening. Multivariate analyses revealed that RVDd, eGFR, and LVEF were independently associated with smooth introduction. In addition, RVDd and eGFR seemed to be better diagnostic parameters for longer usage for ASV therapy according to the analysis of receiver operating characteristics curves.RV enlargement, eGFR, and LVEF are associated with the smooth introduction of ASV therapy in CHF inpatients.

Effects of early diuretic response to carperitide in acute decompensated heart failure treatment: A single-center retrospective study

Background Diuretic response is a strong predictor of outcome for admitted patients of acute decompensated heart failure (ADHF). However, little is known about the effects of early diuretic response to carperitide. Methods We retrospectively analyzed records of 85 patients hospitalized for ADHF who received carperitide as initial treatment and <40 mg furosemide during the early period. The eligible patients were divided into good diuretic responder (GR) group and poor diuretic responder (PR) group on the basis of median urinary volume. Results The PR group demonstrated older age, lower body mass index (BMI), lower estimated glomerular filtration rate, and higher blood urea nitrogen (BUN) level, left ventricular ejection fraction, and β-blockers prescribed at baseline than the GR group. The incidence of worsening renal function (WRF) was significantly higher in the PR group than in the GR group. There was no correlation between early intravenous furosemide dose and urinary volume (Spearman correlation, ρ = 0.111, p = 0.312). Multivariate analysis showed that the statistically significant independent factors associated with poor diuretic response to carperitide were BMI (Odds ratio (OR) = 0.82, 95% confidence interval (CI) 0.68–0.94, p = 0.004) and BUN (OR = 1.07, 95%CI 1.01–1.15, p = 0.018). Kaplan–Meier analysis indicated a lower event-free rate in the PR group than in the GR group (log-rank, p = 0.007). Conclusions BMI and BUN levels on admission were significant determinants of early poor diuretic response to carperitide. Early poor diuretic response to carperitide was associated with future poor outcomes.

Hereditary transthyretin amyloidosis associated with a transthyretin variant Thr59Arg

Department of Neurology, Kumamoto University, Kumamoto, Japan, Department of Molecular Physiology, Faculty of life Sciences, Kumamoto University, Kumamoto, Japan, Department of Morphological and Physiological Sciences, Kumamoto University, Kumamoto, Japan, Department of Laboratory Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan, Cardiovascular Division/Division of Coronary Heart Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan, Division of Diabetes and Metabolism, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan, Diagnostic Unit for Amyloidosis, Department of Neurology, Kumamoto University Hospital, Kumamoto, Japan

Recurrent coronary artery dissection of left main trunk initially presented with normal coronary angiography

Although spontaneous coronary artery dissection (SCAD) is usually diagnosed by coronary angiography, diagnosis may be missed because of various presentations and imperfections of coronary angiography. We report a case of a 41-year-old female with pregnancy-related SCAD who presented with cardiac arrest. Initial coronary angiography was normal without intimal flap. Unexpectedly, 4 days after admission, SCAD in left main trunk was revealed with recurrent myocardial infarction. Intimal flap was sealed at the time of first angiography and this is an interesting point that made us report this case. SCAD is a rare but not negligible cause of not only acute myocardial infarction but also sudden cardiac arrest even if first coronary angiography is normal. <Learning objective: In a case of a young post-partum woman with resuscitated sudden cardiac arrest who has normal coronary artery, intensive observation is needed. We should be aware that spontaneous coronary artery dissection is a rare but not negligible cause even if initial coronary angiography is normal.>.

Hemodynamic response to sildenafil in patients with decompensated congestive heart failure can be predicted by deceleration time of transmitral flow.

Aim: How sildenafil acutely provides hemodynamic alterations in patients with decompensated congestive heart failure remains unknown. The aim of this study was to investigate whether myocardial and/or hemodynamic conditions affect hemodynamic response to sildenafil in patients with decompensated heart failure. Methods and Results: Twenty-five consecutive patients with decompensated congestive heart failure were enrolled. The patients underwent echocardiography before and 1 hour after a single oral administration of sildenafil (20 mg). Sildenafil decreased pulmonary vascular resistance by 24% (P < 0.05), and increased left ventricular (LV) time–velocity integral by 17% (P < 0.05). Alteration of the ratio of peak velocity of early LV filling to early diastolic myocardial velocity (E/E′), an indicator of LV filling pressure, following administration of sildenafil, negatively associated with the deceleration time of early filling wave (DcT) at baseline. Patients with baseline DcT ≥200 milliseconds (n = 11) exhibited E/E′ increase, whereas patients with baseline DcT <200 milliseconds (n = 14) exhibited E/E′ decrease. Conclusions: Administration of sildenafil elevated LV filling pressure in decompensated heart failure patients with shortened deceleration time of early diastolic transmitral flow.

IMPACTS OF ANTI-DIURETIC HORMONE BY SALT SUPPLEMENTATION IN ACUTE DECOMPENSATED HEART FAILURE

Recent reports have provided findings that severe salt restriction may be harmful in acute decompensated heart failure (ADHF). We have reported that salt supplementation enhances diuretic effects in ADHF. Salt administration generally increases a plasma anti-diuretic hormone (ADH) level. It induces