SESSION TYPE: Cardiovascular Student/Resident Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Pulmonary hypertension is a progressive disease of the pulmonary circulation that leads to right heart failure and death. Existing therapies in common use are pulmonary vasodilators, and there is no therapy addressing the failing right ventricle. This series describes the novel use of hemodialysis with ultrafiltration for volume control in right heart failure due to pulmonary hypertension.
CASE PRESENTATION: We present three patients with pulmonary hypertension followed at an academic medical center pulmonary hypertension clinic. All patients developed class IV right heart failure while on optimal therapy with combination pulmonary vasodilators. They were each admitted multiple times with volume overload requiring intravenous diuretics. They progressively developed cardiorenal syndrome requiring hemodialysis. Each patient had an improvement in functional class and had no more hospitalizations for volume overload. Hypotension during hemodialysis was common and required down-titration of their pulmonary vasodilators and initiation of midodrine. Two of the three patients are alive and continue to be followed closely. Our third patient died of an unrelated neurologic problem.
DISCUSSION: In this series, three patients with right heart failure due to refractory pulmonary hypertension responded well to the novel use of hemodialysis for volume control. In each case, hypotension during treatment necessitated initation of midodrine and decreased dosages of pulmonary vasodilators. Once volume overload was controlled with ultrafiltration, each patient clinically improved despite receiving less direct therapy for pulmonary hypertension. Functional class was improved in each case, and none have required hospitalization related to pulmonary hypertension over a combined 67 months following initiation. We note that their life expectancy has been extended beyond that expected for patients with class IV right heart failure . We hypothesize that controlling volume improves right ventricular function and dysynchrony, leading to improved outcomes. We recommend further study of hemodialysis with ultrafiltration in patients with pulmonary hypertension who develop cardiorenal syndrome and refractory volume overload.
CONCLUSIONS: The use of hemodialysis in three patients with pulmonary hypertension complicated by cardiorenal syndrome and refractory volume overload resulted in improved functional class and decreased hospitalizations. Hemodialysis in this population should be further studied.
1) D'Alonzo et al. Survival in patients with primary pulmonary hypertension: results from a National Prospective Registry. Annals of Internal Medicine 1991. 115: 5: 343-349.
DISCLOSURE: The following authors have nothing to disclose: Lindsey Barnes, Dan Grinnan
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