Novel Devices for the Cardiorenal Syndrome in Heart Failure
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(2020) 22:23
Heart Failure (W Tang, Section Editor)
Novel Devices for the Cardiorenal Syndrome in Heart Failure Maria Rosa Costanzo, MD, FACC, FAHA, FESC Address Heart Failure Research, Advocate Heart Institute, Edward Hospital Center for Advanced Heart Failure, 801 South Washington Street, Naperville, IL, USA Email: [email protected]
* Springer Science+Business Media, LLC, part of Springer Nature 2020
This article is part of the Topical Collection on Heart Failure Keywords Heart failure I Cardiorenal syndrome I Congestion I Diuretics I Devices
Abstract Purpose of Review Reduced responsiveness to diuretics is ubiquitous and multifactorial in heart failure and portends poor outcomes. Due to the limitations of current diuretic approaches, there is an enormous unmet clinical need for more effective fluid removal methods in heart failure patients. Recent Findings Novel volume management approaches include veno-venous ultrafiltration, peritoneal-based sodium and water removal methods, controlled diuresis, transvenous renal venous decongestion, catheter-deployed pumps in the descending aorta to increase renal perfusion, device-driven increase of lymphatic flow into the venous system, and catheter-based splanchnic nerve modulation. Summary Overall novel fluid management therapies are at an early stage of development, with some still in pre-clinical trials and others having been studied in first-in-man trials with a small number of subjects. Further investigation of novel fluid management methods should focus on assessment of safety, ease of use, candidates’ selection, reproducibility of effects across heart failure patient populations, and costs.
Introduction Reduced responsiveness to diuretics is ubiquitous and multifactorial in heart failure (HF) patients regardless of left ventricular ejection fraction (LVEF) [1•]. Due to absolute or relative decrease in cardiac output (CO), the kidney behaves as if there were dehydration when dehydration is absent [2••]. Manifestations of this renal
response are a decrease in glomerular filtration rate (GFR) and increase in serum creatinine levels (sCr). Furthermore, diuretics’ effectiveness decreases with progression of HF [1•, 3]. Impaired absorption decreased renal blood flow, azotemia, and proteinuria result in reduced diuretics’ concentrations in the tubular lumen
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Curr Treat Options Cardio Med
[1•]. The chronic use of a diuretic targeting a specific area of the nephron, induces compensatory adaptation in different renal tubular segments which may negate sodium and water elimination in the urine [1•]. Among 9 50,000 patients enrolled in the ADHERE (Acute Decompensated Heart Failure National Registry) study, only 33% lost ≤ 2.27 kg (5 lbs.), and 16% gained weight during hospitalization [4]. With conventional diuretic therapies, nearly 50% of hospitalized HF patients are discharged with residual fluid excess [4]. Inadequate decongestion sets the stage for re-hospitalizations, which increase morbidity and mortality regardless of patients
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