Case Studies in Advanced Monitoring: OptiVol

W. H. Wilson Tang, MD

Assistant Professor in MedicineCleveland Clinic Lerner College of Medicine of Case

Western Reserve UniversityAssistant Program Director

General Clinical Research Center (GCRC)Section of Heart Failure & Cardiac

Transplantation MedicineCleveland, Ohio

EF, ejection fraction; ICD, implantable cardioverter defibrillator; AV, atrioventricular.

M.L.H.: Medical History

67-year-old female

Long history of dilated (nonischemic) cardiomyopathy with mitral regurgitation with mild symptoms

Outside echo: EF 20%, 3+ mitral regurgitation

Epicardial lead placement of biventricular pacer/ICD in February 2005, with subsequent monthly admissions

AV nodal ablation in April 2005 for poorly controlled atrial fibrillation

Referred for evaluation for transplantation versus advanced surgical therapies

June 2005: Medications

Amiodarone 200 mg daily

Digoxin 0.125 mg daily

UroMag 140 mg daily

Warfarin 2.5 mg daily

Aspirin 81 mg daily

Captopril 25 mg three times daily

Metoprolol succinate 25 mg daily

Furosemide 80 mg daily

Potassium 20 mEq daily

June 2005: Initial Clinic Visit

Appeared lethargic, mild respiratory distress

ACC Stage C-D, NYHA III

Weight 207 lbs, height 5’ 6’’

BP 98/65 mm Hg, pulse 88 (irregular)

JVP 8-10 cm

Prominent S3, with 2/6 systolic murmur at apex

Decreased pedal pulses, cool extremities but no significant edema

Sluggish due to dyspnea, but nonfocal neurological signs

Admitted for hemodynamically tailored therapy, requiring transient dobutamine and furosemide IV

Discharged on home dobutamine infusion

ACC, American College of Cardiology; NYHA, New York Heart Association; BP, blood pressure; JVP, jugular venous pressure.

July 2005: Hospitalization

Re-admitted for congestive heart failure

Hemodynamically tailored therapy with switch toIV milrinone infusion

Coronary sinus lead revision with InSync Sentry implantation

Slow titration of metoprolol succinate in attempt to control rapid atrial fibrillation

Stable on furosemide 40 mg daily and home milrinone infusion at discharge

September 2005: Clinic Visit

Follow-up:– Returns to clinic with no improvement in physical activity

and dyspnea– BP 88/50 mm Hg, pulse 76 (irregular), weight 209 lbs– JVD 9 cm, prominent S3, 2/6 systolic murmur (unchanged)– Scanty rales at right base– 1+ pedal edema, warm extremities– Laboratory evaluation:

• Sodium 135 mmol/L

• BUN 22 mg/dL

• Creatinine 0.9 mg/dL

• BNP 1,968 pg/mL

September 2005: Cardiac Compass with OptiVol

Plan:

– Increased furosemide to 40 mg twice daily

– Added spironolactone 25 mg daily

– Continue milrinone infusion

– Close monitoring of congestive symptoms

OptiVol fluid index>200

160

120

80

40

0

DailyReference

Oct 05Fluid

>100

90

80

70

60

0Aug 05 Oct 05

50

Thoracic Impedance (ohms)

Aug 05

048

24201612

AT/AF total hours/day

<50

100

>200

150

0

4

1

32

>1201008060

<40

80<40

160100

>200

250

7550

100

Oct 05Aug 05

V. Rate during AT/AF (bpm)

Max/day Avg/day

Patient activityhours/day

Avg V. rate (bpm) Day Night

Heart rate variability (ms)

% Pacing/day Atrial Ventricular

October 2005: Follow-up Clinic Visit

Follow-up with good diuresis and 18-lb weight loss

Improved symptoms and activity level

No JVD, regular rate and rhythm, no edema

Laboratory:– BNP reduced to 1,213 mg/dL from 1,968 mg/dL– Sodium improved to 138 mmol/L– Stable creatinine at 0.8 mg/dL

Furosemide dose reduced to 40 mg daily, metoprolol succinate at 50 mg daily

February 2006: Follow-up Clinic Visit

Noticed 3-lb weight gain

BP 120/65 mm Hg, pulse 75 (regular)

Symptoms overall unchanged

Mild JVD, cardiac examination unchanged, no edema

Laboratory evaluation:– Sodium 141 mmol/L

– Creatinine 0.9 mg/dL

– BNP 794 pg/mL

February 2006: Cardiac Compass with OptiVol

OptiVol fluid index>200

160

120

80

40

0

DailyReference

Oct 05Fluid

>100

90

80

70

60

40Aug 05 Oct 05

50

Thoracic Impedance (ohms)Aug 05

048

24201612

AT/AF total hours/day

<50

100

>200

150

0

4

1

32

>1201008060

<40

80<40

160100

>200

250

7550

100

Oct 05Aug 05

V. Rate during AT/AF (bpm)

Max/day Avg/day

Patient activityhours/day

Avg V. rate (bpm) Day Night

Heart rate variability (ms)

% Pacing/day Atrial Ventricular

Dec 05 Feb 06

Dec 05 Feb 06

Feb 06Dec 05

AT/AF, atrial tachycardia/atrial fibrillation; V. rate, ventricular rate.

February 2006: Follow-up Clinic Visit

Increased furosemide to 40 mg twice daily for 4 days then resumed 40 mg once daily

Prompt resolution of congestion and OptiVol index

Repeat BNP 336 pg/mL

NYHA II-III with slow weaning of milrinone infusion

March 2006: Cardiac Compass with OptiVol

Got a call from home nurse regarding recent 8-lb weight gain later, asked to readjust milrinone dose

Phone contact revealed no significant signs and symptoms of edema.

No change in OptiVol index

Further inquiry revealed increase night-time snacking and food intake

OptiVol fluid index>200

160

120

80

40

0

DailyReference

Oct 05Fluid

>100

90

80

70

60

40

Aug 05 Oct 05

50

Thoracic Impedance (ohms)

Aug 05

Dec 05 Feb 06

Feb 06Dec 05

Take-Home Points

OptiVol fluid index tracks with clinical status in the setting of congestion:– Clinical signs and symptoms of congestion

– Plasma BNP levels

– Fluid weight (but not fat)

Precedes development of overt symptoms

Tracks responses to therapy

Need to evaluate other parameters (activity, rhythm, heart rate variability) and clinical status in parallel with OptiVol index