Old therapies of new fashion: a better way to use diuretics and normal saline in acute decompensated heart failure

Clinical case: A 40 years old man was admitted for acute decompensated heart failure (ADHF). He was known for Arrythmogenic Right Ventricle dysplasia (ARVD) since 12 years. 3 years before admission a Cardiac Magnetic Resonance was performed showing RV dilatation with moderate biventricular dysfunction (RVEF 36%, LVEF 44%) and RV fibrosis (LGE+ with non-ischaemic pattern). Two years before admission he was hospitalized for ADHF with dyspnea. During hospitalization episodes of sustained ventricular tachycardia occurred. A coronary angiography was normal and a permanent ICD was implanted. On admission he was symptomatic for dyspnea (NYHA class III/IV), he reported reduced urine output and a weight increase of +12 Kgs in the last 4 weeks. On examination: respiratory rate 23/min with slight orthopnea, jugular vein distension at 45°, pitting edema at both legs and hepatomagaly. ECG showed sinus rhythm, atrial enlargement, small complexes in the peripheral leads with incomplete right bundle branch block and RV strain. An epsilon wave was noted in the anterior precordial leads (Fig.1A). A cardiac echo showed a severe LV and RV dilatation and dysfunction (Fig.1B) while a cardiopulmonary exercise test showed exercise cardiogenic limitation with a peak Vo2 of 39% of the predicted and oscillatory breathing. Patient was treated with i.v. furosemide (40 mg bolus followed by continuous infusion) with matched de-hydration to obtain a more controlled and physiologically-oriented dehydration. This was achieved with the RenalGuard System. Current evidences on its use comes from studies on acute kidney injury prevention in patients undergoing intravascular contrast exposure. In this specific field, furosemide-induced high-volume diuresis with concurrent maintenance of intravascular volume through matched hydration, by the RenalGuard, is now considered a recommended strategy. In this patient we set an estimated daily targeted negative fluid balance of 2.4 liters (-100 ml/h, Fig.1C). Results are shown in Fig.1D. In summary the patient was successfully treated with i.v. diuretics and normal saline matched with RenalGuard with a 7.5 Kgs weight reduction and NYHA class improvement. During the treatment kidney function didn’t worsen (a mild improvement in creatinine and BUN was noted). After one month he was on stable clinical condition with stable kidney function and he was started on Sacubitril/Valsartan according to the guidelines. He was also referred to a transplant center.