This group will receive conventional evidence-based medications with up-titration to maximal tolerable dose. The evidence-based medications include angiotensin converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, mineralocorticoid receptor antagonist, ivabradine and entresto. Which evidence-based medications will be started first depends on the decision of in-charge doctors without strict regulation. However, all evidence-based medications should be up-titrated to maximal tolerable dose. (Excuse me! Up-titration of evidence-based medications in heart failure isn't multiple intervention. Those medications should be prescribed in each heart failure case if no contraindication was noted.)

another group will receive low-dose hydralazine initially with rapid up-titration, if no adverse effect including hypotension with worsening low cardiac output sign, skin rash and joint pain occurred. Since the half-life of hydralazine is around 4-6 hours and 3-5 half-life achieves the steady blood concentration, up-titration of hydralazine will be done per 1-2 days. For example, initial dose of hydralazine would be 25 mg tid and the dose would be 50 mg bid next day if no adverse effect occurred. Following this rule, one week is enough to reach high-dose hydralazine with daily dose of 300-400 mg.

Systolic Heart Failure Stage D (Disorder)

Mitral Regurgitation

randomized in 1 to 1 fashion After discharge, high-dose hydralazine is maintained except any adverse effect and up-titration of other evidence-based medications to maximal tolerable dose will be done. The dose of medications is adjusted by clinical signs, especially peripheral perfusion, not only simply by blood pressure. If participant had low blood pressure (for example, systolic blood pressure less than 90 mmHg) but no sign of postural hypotension, or low cardiac output (cold limbs, decreased urine output, dizzy), the investigators will keep up-titration of medications.

evidence-based medications vs. high-dose hydralazine + evidence-based medications

E-Da hospital

The Prognostic Impact of Using High-dose Hydralazine in Severe Systolic Heart Failure With Hemodynamically Significant Mitral Regurgitation

Hospitalization for HF is defined as a hospital stay of at least 1 night for treatment of a clinical syndrome with at least two of the following symptoms: paroxysmal nocturnal dyspnea, orthopnea, elevated jugular venous pressure, pulmonary rales, a third heart sound, cardiomegaly on chest radiography, or pulmonary edema on chest radiography.

The certification of death is based on death records, death certificates, and hospital medical records

Shih-Hung Hsiao

Staff of Cardiology, Principal Investigator, Clinical Associate Professor

Kaohsiung Veterans General Hospital.

E-DA Hospital

This prospective study will recruit 400 patients aged 18 years or older, and hospitalization to E-Da Hospital for acute decompensated heart failure due to severe left ventricular systolic dysfunction combined with hemodynamically significant mitral regurgitation. Severe systolic dysfunction and hemodynamically significant mitral regurgitation are defined as left ventricular ejection fraction less than 35% and mitral regurgitant volume more than 45 ml (more than moderate degree), respectively. All participants will be randomly divided into two groups according to 1 to 1 fashion. One group will receive conventional evidence-based medication with up-titration to maximal tolerable dose and another group will receive low-dose hydralazine initially with rapid up-titration, if no adverse effect including hypotension with worsening low cardiac output sign, skin rash and joint pain occurred.

Right Ventricular Dysfunction

Rheumatic Heart Disease

Right Ventricular Echo Assessment in Mitral Valve Replacement

Right Ventricular Function After Mitral Valve Replacement in Rheumatic Heart Disease Patients With Pulmonary Hypertension: Short Term Follow up

change in TAPSE (Tricuspid annular plane systolic excursion )

TDI (Tissue doppler imaging) across the lateral tricuspid annulus : peaked S' velocity

change in RVFAC : Right ventricular calculated ejection fraction by mean of change in RV systolic and diastolic volumes

PASP measured by CW doppler across tricusped valve regurgetant jet

The evaluation of reverse right ventricle (RV) remodelling, assessed as reduction/modification of the end diastolic and end systolic RV diameters with respect to pre-surgery

Percentage of patients with moderate to severe TR at 3 months after surgery

Modification of NYHA class at 3 months after surgery

Mortality within hospital stay or 3 months postoperative.

Ahmed M. Nasr

Assistant Lecturer Cardiothoracic surgery

Assiut University

The liberal group will receive 1500 mL of crystalloid solution during the cesarean section. This is the non-intervention arm once that 1500 ml of crystalloid is the amount usually used during caesarean.

The restrictive group will receive 250 mL of crystalloid solution during cesarean section.

Liberal Fluid Therapy

The restrictive group will receive 250 mL of crystalloid solution during cesarean section.
Restrictive Fluid Therapy: The intervention in this randomized clinical trial is fluid restriction during cesarean section. The restricted group will receive 250 mL of crystalloid during surgery.

Restrictive Fluid Therapy

Total

Gender

Gestational age (weeks)

Body mass index (kg/m2)

Twin pregnancy

Chronic hypertension

Previous preeclampsia

Diabetes Mellitus

Systolic blood pressure (mmHg)

Diastolic blood pressure (mmHg)

Renal function evaluated through creatinine levels in three moments: preoperative, first and second postoperative days.

Renal Function in Severe Preeclampsia With Restrictive Fluid Therapy

Evaluate new marker of renal injury (NGAL) in the specific population of patients with severe preeclampsia, comparing the values of first and second postoperative days to baseline.

Neutrophil Gelatinase-associated Lipocalin (NGAL) as New Marker of Renal Injury in Preeclampsia

Evaluate new marker of renal injury (Cystatin C) in the specific population of patients with severe preeclampsia, comparing the values of first and second postoperative days to baseline.

Cystatin C as New Marker of Renal Injury in Preeclampsia

Proteinuria in severe pre-eclampsia submitted to cesarean section under different regimes of hydration. Analyses in pre-operative and post-operative period.

Proteinuria in Severe Pre-eclampsia Submitted to Cesarean Section Under Different Regimes of Hydration

Compare platelets count in the restrictive and liberal groups during the first and second post-operative days.

Platelets in Restrictive Fluid Management of Severe Preeclampsia

Compare International Normalized Ratio (INR) of Prothrombin Time (PT) in the restrictive and liberal groups in preoperative, first and second day postoperative.
PT is expressed in seconds and the entered values represented the INR of PT among study participants and a control population.

International Normalized Ratio (INR) of Prothrombin Time (PT) in Restrictive Fluid Management of Severe Preeclampsia During Cesarean Section

Urine output during cesarean section in severe pre-eclampsia under two different regimes of hydration (restrictive and liberal)

Urine Output During Cesarean Section in Severe Pre-eclampsia

Compare activated partial thromboplastin time (APPT) and relation with control (R) in the restrictive and liberal groups.
APPT is a laboratory test that evaluates the efficiency of the intrinsic pathway of coagulation. The unit of measure is seconds and the results are presented as relation (R) with control.

Activated Partial Thromboplastin Time in Restrictive Fluid Management of Severe Preeclampsia During Cesarean Section

Renal dysfunction was stratified by the Acute Kidney Injury Network (AKIN) index in three stages, in terms of creatinine increase from baseline: stage 1 included an interval of 150-200%, stage 2 200%-300%, and stage 3 more than 300% or hemodialysis

Postoperative Renal Dysfunction Evaluated by the Acute Kidney Injury Network (AKIN) Index

Overall Study

M.D. Wallace Andrino da Silva

Pre-Eclampsia

The intervention in this randomized clinical trial is fluid restriction during cesarean section. The restricted group will receive 250 mL of crystalloid during surgery.

mitral valve stenosis/وذمة

The Prognostic Impact of Using High-dose Hydralazine in Severe Systolic Heart Failure With Hemodynamically Significant Mitral Regurgitation

Right Ventricular Echo Assessment in Mitral Valve Replacement

Restrictive Fluid Therapy in Severe Preeclampsia

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