Volume control: a reliable option in the management of 'refractory' congestive heart failure.

CAVH can be effective in severe hypervolemic states, which are generally major hemodynamic abnormalities associated with refractory congestive heart failure, and not infrequently may have a poor renal response to diuretics and vasodilators. Reduced vascular volume with CAVH is accompanied by lower preload and afterload and thus decreased heart size. As a result, cardiac efficiency and contractility improve and oxygen demand is reduced. The temporal progression of congestive heart failure from a mild to a severe state need not be a sign of progressive pathology of heart muscle but rather a result of feedback circuits in which failure begets failure and leads to progressive cardiac enlargement, progressive hypervolemia, and peripheral edema. An appreciation of this concept permits a more optimistic approach to the management of congestive heart failure. Thus, the effective use of CAVH in reducing vascular volume and peripheral edema may reverse "refractory" congestive heart failure and prolong life.