Introduction
Following open heart surgery, particularly in patients with valvular heart disease and those with pre-operative congestive heart failure, late volume shifts may occur. Whether related to inadequate diuretic administration, dietary indiscretion, or medication interaction; following discharge, patients may present emergently with peripheral and/or pulmonary edema. The removal of free water is required and diuretic therapy alone may not suffice.

Case History
A 62-year-old female with mitral and tricuspid insufficiency, who had an enlarging left ventricular chamber and decreasing ejection fraction, was referred for surgery. Post-cath, she developed contrast induced nephropathy (Creatinine reaching 2.7 mg%). She was admitted with pulmonary hypertension and fulminant congestive heart failure. Surgical repair was accomplished with a P-2 quadrangular mitral leaflet resection, placement of a #28 Taylor ring, a DeVega tricuspid annuloplasty and closure of a patent foramen ovale.

In the immediate postoperative period, the patient was treated with diuretics and had mild bilateral pleural effusions. Her postoperative course was otherwise uncomplicated, and she was discharged on diuretics (Bumex® 2mg PO bid) with her weight declining. Seventy-two (72) hours following discharge, the patient re-presented with an eight (8) pound weight gain, shortness of breath, decreased urine output, hyponatremia (Na = 129), pleural effusions and peripheral edema.

A PICC line was placed in the right antecubital fossa and the patient underwent our systems form of filtration. Using our system, she underwent two eight (8) hour runs removing over 7 kg of fluid bringing her to preoperative weight. The medical regimen was adjusted and she was discharged without peripheral edema or shortness of breath. She has required no further hospitalizations.

Comment
This situation represents an example of using the peripheral UF unit to manage late postoperative fluid retention. The patient had congestive heart failure and edema preoperatively, and in the early postoperative period, and acute renal insufficiency, which limited effective diuresis. In spite of being discharged on an adequate medical regimen, there were significant fluid shifts following discharge that resulted in pulmonary and peripheral edema. The response to diuretics was inadequate on readmission, and fluid removal with our system resolved the hyponatremia and edema, did not impact potassium levels, and limited the aggressive use of diuretics resulting in a shortened hospital stay.

Case history courtesy of:

Director of Cardiovascular Surgery

Minnesota