Author + information
- Thach Nguyen1,2,
- Bui Pham Thai Hoa2,
- Hanh Nguyen Hieu Le2,
- Tuan Si Nguyen2,
- Luong Thanh Phuoc2 and
- Gianluca Rigatelli3
It is difficult to diagnose fluid overload or questionable heart failure (HF) after TAVR or MitraClip especially if these patients had concomitant severe chronic obstructive pulmonary disease (COPD), cirrhosis or chronic kidney disease (CKD) or while on respirator. In a normal person, the amount of blood going down to the leg via the common femoral artery (FA) should be the same amount which returns to the heart via the femoral vein (FV). This is manifested by the similar size of the FA and FV. If the size of the FV is significantly larger, there is fluid overload in the venous system.
Patients with questionable diagnosis of HF after TAVR or MitraClip while having severe comorbidities (COPD, cirrhosis, CKD or on ventilator) were enrolled. The control group underwent physical exam (PE), CXR and BNP level measured. The study group underwent the same protocol PLUS an ultrasound checking the size and expansion of the FV (SEFV). The image was the coronal plane proximal to the bifurcation of the superficial (SFA) and deep femoral artery (PFA). The principle of this test is that the volume of blood going through the FA and returning through the common FV should be the same. In normal condition, the FV is a little larger than the FA. If the size of the FV at baseline is 2 times larger than the FA, the patient has significant fluid overload. If the FV can expand >1.5 times during cough, the test showed that the venous system can accommodate more fluid if needed. In patients with HF, the FV does not expand with cough. Both groups received treatment according the PE or the SEFV.
With the SEFV results, all study (50) patients had accurate confirmation to be overloaded or euvolemic. Compared with control, the patients who were treated according to the SEFV results improved with less medications (2.5 vs 5, p<0.05), at higher doses of diuretics (60mg of furosemide vs 30mmg, p<0.05) without having renal failure (2 vs 14, p<0.05), shorter ICU (1.5 vs 3 days, p,0.05) hospital stay (3.4 vs 5 days).
The SEFV test was more accurate in confirming the fluid status of patient after TAVR or MitraClip with complex co-morbidities. Under the guidance of SEFV, the patients improved with higher doses of diuretics without causing more renal failure. Shorter time in ICU and hospital. The SEFV is a better test to confirm HF and guide its treatment in complex patients after TAVR or MitraClip.