Congestive Heart Failure, Pleural Effusions, Chronic, Shortness of Breath
Conditions
Keywords
congestive heart failure, pleural effusion, shortness of breath, tunneled pleural catheter, thoracentesis
Brief summary
Congestive heart disease (CHF) can frequently cause transudative pleural effusions, some of which do not completely resolve with diuretics alone. These effusions can cause significant morbidity, leading to ongoing dyspnea and hypoxia, resulting in additional office and hospital visits. TREAT-CHF is a randomized trial studying tunneled pleural catheter (TPC) versus standard medical management for the treatment recurrent symptomatic pleural effusions secondary to CHF that are refractory to maximal medical therapy. TREAT-CHF will study whether the addition of a TPC can improve quality of life and minimize health care utilization over the one year following insertion.
Detailed description
TREAT-CHF is a randomized trial studying tunneled pleural catheter (TPC) versus standard medical management for the treatment recurrent symptomatic pleural effusions secondary to CHF that are refractory to maximal medical therapy. All trial participants will be adults with congestive heart failure (CHF) already managed with maximal medical therapy, as determined by their cardiologist or primary physician. Patients will demonstrate recurrent transudative or pseudoexudative pleural effusions caused solely by CHF that have not been controlled with medical therapy alone. Included patients must also show documented subjective symptomatic relief with thoracentesis. Patients will be randomized to the intervention group or control group. The intervention group will receive a tunneled pleural catheter (TPC) in addition to their current medical treatment. The control group will continue with medical therapy by their referring physician and serial thoracenteses when clinically appropriate. Patients will then be followed over the course of once year after enrollment. The TPC will be drained daily for symptomatic relief. Several outcomes, including quality of life based on periodic self-survey and healthcare utilization determined by chart review (emergency room visits and hospital stays), will be studied. Adverse outcomes of TPC insertion and sequelae of frequent pleural space drainage will be documented.
Interventions
DEVICEtunneled pleural catheter
Placement of a tunneled pleural catheter through the chest wall into the pleural space to drain the patient's chronic pleural effusion. The catheter is an indwelling device that will be drained from home three times per week by nursing care, the patient, or patient's family.
Sponsors
University of California, Los Angeles
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
SINGLE (Outcomes Assessor)
Masking description
The subjects and providers will not be blinded, since it will be apparent which patients received a pleurx catheter. Outcomes measured by survey and chart review will be scored and analyzed in a blinded fashion.
Intervention model description
There will be an intervention group (receiving the tunneled pleural catheter) and a usual care group.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Age \> 18 years of age at enrollment 2. Able to give consent 3. Documented heart failure defined by echocardiography demonstrating depressed left ventricular ejection fraction and/or left ventricular diastolic dysfunction 4. Recurrent and symptomatic pleural effusions refractory to medical management 5. Maximal medical management will be determined by the referring provider a. This should include use of at least three of the classes of medications that are standard of care for heart failure: i. Angiotensin converting enzyme inhibitor or angiotensin receptor blockers ii. Beta blockers iii. Loop diuretics iv. Potassium-sparing diuretics b. If the patient is not on at least three drugs from the above classes, documentation of drug intolerance must be present 6. Documented subjective symptomatic relief after thoracentesis and drainage of the pleural space 7. Pleural fluid clinically determined to be due only to CHF 8. Pleural fluid analysis consistent with transudate or pseudoexudate a. Transudate: defined by Light's criteria, all of the following must occur, i. Pleural:serum lactate dehydrogenase (LDH) \< 0.6 ii. Pleural LDH \< 2/3 x upper limit of normal of serum LDH iii. Pleural:serum protein \< 0.5 b. Pseudoexudate: defined by all of the following, i. Pleural:serum LDH \> 0.6 but \< 1 ii. Pleural:serum protein \< 0.5 iii. Serum-pleural protein gradient \> 3.2 and/or serum-pleural albumin gradient \> 1.2 9. Anticipated outpatient management
Exclusion criteria
1. Imminent death within 1 month 2. Heart transplant candidate 3. Lone right sided heart failure with normal left sided cardiac function 4. Active malignancy 5. Active pulmonary infection 6. Alternate etiology for pleural effusion origin 7. On hemodialysis during enrollment 8. Exudative pleural effusion, defined as any effusion that dose not meet criteria for transudate or pseudoexudate 9. Contraindication for TPC insertion
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in quality of life scores from baseline as measured by the Minnesota Living with Heart Failure Questionnaire | Change from baseline at 3 time points over the year of follow up (3, 6, and 12 months) | Quality of life will be measured by the Minnesota Living with Heart Failure Questionnaire at four time points |
| Incidence of hospitalizations and emergency room encounters | 1 year post-enrollment | Measurement of all significant health care visits, including hospitalizations and emergency room encounters |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of pleural procedures | 1 year post-enrollment | By convention, the intervention group will have one pleural procedure (TPC placement). Any additional thoracenteses, video-assisted thoracoscopic surgery, or chest tubes on either side of the chest will be documented for both groups. Removal of or manipulation of TPC will not be recorded as an additional pleural procedure. |
| Incidence of pleural space or chest wall infection | 1 year post-enrollment | Pleural space infection is defined as a positive pleural fluid culture. Chest wall infection will be defined clinically, based on the presence of cellulitis surrounding the catheter or catheter tract, or pus draining from the catheter insertion site. |
| Incidence of hemothorax | 1 year post-enrollment | Hemothorax is defined as a pleural hematocrit or red blood cell count (RBC) exceeding 50% that of the serum hematocrit or RBC count. |
| Incidence of trapped lung, loculated pleural effusion, and pneumothorax | 1 year post-enrollment | Trapped lung is defined as a lung that does not expand after pleural fluid drainage leaving a pneumothorax ex-vacuo or hydropneumothorax. Pneumothorax and loculated pleural effusion will be determined based on classic imaging characteristics. |
| All cause mortality | 1 year post-enrollment | All cause mortality |
| Time to pleurodesis among those who achieved pleurodesis | 1 year post-enrollment | The number of days from enrollment (control group) or TPC placement (intervention group) to pleurodesis among those who achieved pleurodesis will be recorded. Pleurodesis is defined as apposition of the parietal and visceral pleural such: (i) that the subject drains less than 10cc on three serial drainages, (ii) there is resolution of the pleural effusion on both chest x-ray (CXR) and chest ultrasound, (iii) the TPC is removed, and (iv) the pleural effusion does not accumulate after TPC removal as evidence by CXR and chest ultrasound. |
| Change from baseline serum albumin | Change from baseline at 3 time points over the year of follow up (3, 6, and 12 months) | serum albumin levels |
| Change from baseline serum creatinine | Change from baseline at 3 time points over the year of follow up (3, 6, and 12 months) | serum creatinine levels |
| Rate of hemodialysis initiation | 1 year post-enrollment | We will record patients who develop worsening renal failure, necessitating initiation of hemodialysis |
| Incidence of pleurodesis | 1 year post-enrollment | Incidence of pleurodesis over the one year after enrollment will be measured. Pleurodesis is defined as apposition of the parietal and visceral pleural such: (i) that the subject drains less than 10cc on three serial drainages, (ii) there is resolution of the pleural effusion on both chest x-ray (CXR) and chest ultrasound, (iii) the TPC is removed, and (iv) the pleural effusion does not accumulate after TPC removal as evidence by CXR and chest ultrasound. |
| New York Heath Association (NYHA) functional class | Change from baseline at 3 time points over the year of follow up (3, 6, and 12 months) | NYHA functional class: I, III, III, or IV |
Countries
United States
Outcome results
None listed