More than 1 million heart failure hospitalizations occur annually, and congestion is the predominant cause. Rehospitalizations for recurrent congestion portend poor outcomes independently of age and renal function. Persistent congestion trumps serum creatinine increases in predicting adverse heart failure outcomes. No decongestive pharmacological therapy has reduced these harmful consequences. Simplified ultrafiltration devices permit fluid removal in lower-acuity hospital settings, but with conflicting results regarding safety and efficacy. Ultrafiltration performed at fixed rates after onset of therapy-induced increased serum creatinine was not superior to standard care and resulted in more complications. In contrast, compared with diuretic agents, some data suggest that adjustment of ultrafiltration rates to patients’ vital signs and renal function may be associated with more effective decongestion and fewer heart failure events. Essential aspects of ultrafiltration remain poorly defined. Further research is urgently needed, given the burden of congestion and data suggesting sustained benefits of early and adjustable ultrafiltration.

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Background Stroke is one of the leading complications during continuous flow-left ventricular assist device (CF-LVAD) support. Risk factors have been well described, though less is known regarding treatment and outcomes. We present a large single center experience on stroke outcome and transplant eligibility by stroke subtype and severity in CF-LVAD patients. Methods 301 patients underwent CF-LVAD (266 HeartMate II (HM II) and 35 HeartWare (HVAD)) between 1/1/2008 and 4/1/2015. Stroke was defined as a focal neurological deficit with abnormal neuroimaging. Intracerebral hemorrhage (ICH) definition excluded subdural hematoma and hemorrhagic conversion of an ischemic stroke (IS). Treatment in IS included intra-arterial embolectomy (IAE) when appropriate; treatment in ICH included reversal of coagulopathy. Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS). Outcomes were in-hospital mortality and transplant status. Results 40 patients suffered a stroke: 8 ICH (4 HM II, 4 HVAD) and 32 IS (26 HM II, 6 HVAD). Among 8 ICH there were 4 deaths (50%) (NIHSS 18.8±13.7 vs 1.8±1.7 in survivors, p=0.049). Among 32 IS, 12 had hemorrhagic conversion and 5 were treated with IAE. There were 9 deaths (28%) (NIHSS 16.2±10.8 vs 7.0±7.6 in survivors, p=0.011). Among the 32 IS patients, 12 underwent transplant and 1 is awaiting transplant; no ICH patients were transplanted. Conclusions In-hospital mortality after stroke is significantly affected by the initial neurological impairment. Patients with IS appear to benefit the most from in-hospital treatment and often make sufficient recovery to be able to progress to transplant.

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