Tunneled Pleural Catheters for Refractory Effusions Attributed to Congestive Heart Failure (TREAT-CHF) Trial

Study Overview
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Brief Summary
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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
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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.

Official Title
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Tunneled Pleural Catheters for Refractory Effusions Attributed to Congestive Heart Failure (TREAT-CHF) Trial

Conditions
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Pleural Effusions, Chronic, Congestive Heart Failure, Shortness of Breath

Intervention / Treatment
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* Device: tunneled pleural catheter


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age > 18 years of age at enrollment Able to give consent Documented heart failure defined by echocardiography demonstrating depressed left ventricular ejection fraction and/or left ventricular diastolic dysfunction Recurrent and symptomatic pleural effusions refractory to medical management 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 Documented subjective symptomatic relief after thoracentesis and drainage of the pleural space Pleural fluid clinically determined to be due only to CHF 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 Anticipated outpatient management Exclusion Criteria: Imminent death within 1 month Heart transplant candidate Lone right sided heart failure with normal left sided cardiac function Active malignancy Active pulmonary infection Alternate etiology for pleural effusion origin On hemodialysis during enrollment Exudative pleural effusion, defined as any effusion that dose not meet criteria for transudate or pseudoexudate Contraindication for TPC insertion

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: There will be an intervention group (receiving the tunneled pleural catheter) and a usual care group.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention Group<br>This group will receive placement of a tunneled pleural catheter to drain their recurrent, chronic, and symptomatic pleural effusion in addition to their usual medication therapy. | Device: tunneled pleural catheter<br>* 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.<br>* Other names: pleurx catheter placement;|
| No Intervention: Usual Care<br>The control group will continue with medical therapy by their referring physician and serial thoracenteses when clinically appropriate. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in quality of life scores from baseline as measured by the Minnesota Living with Heart Failure Questionnaire | Quality of life will be measured by the Minnesota Living with Heart Failure Questionnaire at four time points | Change from baseline at 3 time points over the year of follow up (3, 6, and 12 months) | 
| Incidence of hospitalizations and emergency room encounters | Measurement of all significant health care visits, including hospitalizations and emergency room encounters | 1 year post-enrollment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| All cause mortality | All cause mortality | 1 year post-enrollment | 
| New York Heath Association (NYHA) functional class | NYHA functional class: I, III, III, or IV | Change from baseline at 3 time points over the year of follow up (3, 6, and 12 months) | 
| Incidence of pleural procedures | 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. | 1 year post-enrollment | 
| Incidence of pleural space or chest wall infection | 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. | 1 year post-enrollment | 
| Incidence of hemothorax | Hemothorax is defined as a pleural hematocrit or red blood cell count (RBC) exceeding 50% that of the serum hematocrit or RBC count. | 1 year post-enrollment | 
| Incidence of trapped lung, loculated pleural effusion, and pneumothorax | 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. | 1 year post-enrollment | 
| Incidence of pleurodesis | 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. | 1 year post-enrollment | 
| Time to pleurodesis among those who achieved pleurodesis | 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. | 1 year post-enrollment | 
| Change from baseline serum albumin | serum albumin levels | Change from baseline at 3 time points over the year of follow up (3, 6, and 12 months) | 
| Change from baseline serum creatinine | serum creatinine levels | Change from baseline at 3 time points over the year of follow up (3, 6, and 12 months) | 
| Rate of hemodialysis initiation | We will record patients who develop worsening renal failure, necessitating initiation of hemodialysis | 1 year post-enrollment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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congestive heart failure, pleural effusion, shortness of breath, tunneled pleural catheter, thoracentesis