1. Case Studies in Advanced Monitoring: OptiVol
W. H. Wilson Tang, MD
Assistant Professor in Medicine Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Assistant Program Director General Clinical Research Center (GCRC) Section of Heart Failure & Cardiac Transplantation Medicine Cleveland, Ohio

2. 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
EF, ejection fraction; ICD, implantable cardioverter defibrillator; AV, atrioventricular.

3. 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

4. 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.

5. July 2005: Hospitalization
Re-admitted for congestive heart failure
Hemodynamically tailored therapy with switch to IV 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

6. 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

7. September 2005: Cardiac Compass with OptiVol
OptiVol fluid index
AT/AF total hours/day 24
Plan:
Increased furosemide to 40 mg twice daily
Added spironolactone 25 mg daily
Continue milrinone infusion
Close monitoring of congestive symptoms
>200 20 16 12
160 8 4
120
V. Rate during AT/AF (bpm)
Max/day Avg/day
>200
150 80
100
<50 40
Patient activity hours/day 4 3 2
Fluid 1
Aug 05
Oct 05
Avg V. rate (bpm) Day Night
>120
Thoracic Impedance (ohms)
100
>100 80
Daily
Reference 60
<40 90
Heart rate variability (ms)
>200
160 80
100 80 70
<40
% Pacing/day Atrial Ventricular
100 60 75 50 50 25
Aug 05
Oct 05
Aug 05
Oct 05

8. 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

9. 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

10. February 2006: Cardiac Compass with OptiVol
OptiVol fluid index
AT/AF total hours/day 24 20
>200 16 12 8
160 4
V. Rate during AT/AF (bpm)
Max/day Avg/day
>200
120
150
100 80
<50 40
Patient activity hours/day 4 3 2
Fluid 1
Aug 05
Oct 05
Dec 05
Feb 06
Avg V. rate (bpm) Day Night
>120
Thoracic Impedance (ohms)
100
>100 80
Daily
Reference 60
<40 90
Heart rate variability (ms)
>200
160 80
100 80 70
<40
% Pacing/day Atrial Ventricular
100 60 75 50 50 25
Aug 05
Oct 05
Dec 05
Feb 06 40
Aug 05
Oct 05
Dec 05
Feb 06
AT/AF, atrial tachycardia/atrial fibrillation; V. rate, ventricular rate.

11. 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

12. March 2006: Cardiac Compass with OptiVol
OptiVol fluid index
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
>200
160
120 80 40
Fluid
Aug 05
Oct 05
Dec 05
Feb 06
Thoracic Impedance (ohms)
>100
Daily
Reference 90 80 70 60 50 40
Aug 05
Oct 05
Dec 05
Feb 06

13. 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