Outpatient Ultrafiltration to Prevent Hospital Readmission During Covid 19 Pandemic in Diuretic Intolerant Patient: Case Study

INTRODUCTION: Heart Failure (HF) is the leading cause of hospitalization among adults greater than 65 years of age in the U.S. and results in over 1,000,000 hospitalizations annually. Despite advances in medical therapeutics, mortality remains high. Adjustments in workflow across hospital systems have been instituted to reduce HF hospitalizations. Ambulatory HF clinics have helped in this regard. In the current COVID-19 pandemic, the need to minimize utilization of hospital resources and limit patient hospital admissions is paramount. Inpatient ultrafiltration (UF) has been utilized to improve congestion in patients with acute decompensated heart failure (ADHF). Less is known of outpatient utilization of UF in the ambulatory HF patient. We present a case of outpatient UF to reduce congestion in an ambulatory HF patient to minimize hospitalization in the era of COVID-19 pandemic. CASE: A 70-year-old female with HF preserved ejection fraction, combined pre and post pulmonary capillary hypertension, with chronic dyspnea on continuous home oxygen, who presented to the HF clinic. The patient had previous multiple hospitalizations due to recurrent congestion, with therapies limited by dermatologic biopsy proven allergy to sulfa based diuretics. She had failed various diuretic regimens with recurrent desquamating whole body rash. She had recurrent weight gain during the COVID-19 pandemic, and again was refractory to outpatient therapies. Given her co-morbidities, she was deemed high risk for COVID-19 exposure. A decision to proceed with outpatient UF was made. The day of outpatient HF clinic visit, we placed a brachial dual lumen 16-gauge extended length catheter. A heparin drip was initiated thirty minutes prior to the start of UF per protocol. Baseline serum creatinine was 1.24 mg/dl and estimated GFR was 44. Initial outpatient session was performed over a total of 4-hours with isolated veno-venous UF utilizing the Aquadex Flex Flow system at a rate of 200 cc/hr fluid removal. The patient completed a total of 4 sessions, and total fluid removal was 4950mL. (Table 1) The patient had immediate improvement in symptoms. DISCUSSION: UF is a method of decongestion that can be used as an alternative to loop diuretics. Simplified UF devices can utilize peripheral venous access, low blood flows, and small extracorporeal blood volume. Previous experience with intermittent outpatient UF utilizing peritoneal dialysis and hemofiltration has been reported, though not widely utilized. This is the first case to report the use of the Aquadex Flex Flow system to provide outpatient UF therapies in the COVID-19 era. CONCLUSIONS: Pre-existing cardiac and pulmonary disease, including congestive HF, increase risk of serious complications from exposure to SARS-COVID-2 virus. We report a novel case of minimizing exposure risk of a congested HF patient using outpatient isolated veno-venous UF in the ambulatory setting.