Cardiac implications of upper-arm arteriovenous fistulas: A case series

Abstract

Background: Cardiovascular disease is a major cause of morbidity and mortality in patients with end-stage kidney disease. Arterio-venous fistulas (AVF), the gold standard for hemodialysis vascular access, are known to alter cardiac morphology and circulatory hemodynamics. We present a prospective case series of patients after creation of an AVF, explore the timeline for changes in their cardiac morphology, and detail considerations for clinicians. Methods: Patients were recruited in 2010 at multiple centers immediately prior to the creation of an upper-arm AVF and the initiation of hemodialysis. Cardiovascular magnetic resonance images were taken at intake before the creation of the AVF, 6-month follow-up, and 12-month follow-up. Image segmentation was used to measure left ventricular volume and mass, left atrial volume, and ejection fraction. Results: Eight patients met eligibility criteria. All eight patients had a net increase in left ventricular mass over enrollment, with a mean increase of 9.16 g (+2.96 to +42.66 g). Five participants had a net decrease in ejection fraction, with a mean change in ejection fraction of −5.4% (−21% to +5%). Upon visual inspection the patients with the largest ejection fraction decrease had noticeably hypertrophic and dilated ventricles. Left atrial volume change was varied, decreasing in five participants, while increasing in three participants. Changes in morphology were present at 6-month follow-up, even in patients who did not maintain AVF patency for the entirety of the 6-month period. Conclusion: All patients included in this prospective case series had increases in left ventricular mass, with variability in the effects on the ejection fraction and left atrial volume. As left ventricular mass is an independent predictor of morbidity and mortality, further research to determine appropriate vascular access management in both end-stage kidney disease and kidney transplant populations is warranted.

When Is Arteriovenous Fistula Dangerous for Hemodialysis Patients?

“…At the follow-up visit, the patients had a mean Qa value of 1158 mL/min, and significantly higher left ventricular mass and dilatation of all cardiac chambers. A recent study reported similar results [8].…”

High-flow arteriovenous fistula and myocardial fibrosis in hemodialysis patients with non-contrast cardiac magnetic resonance imaging

“…Structural heart disease such as increased LVM or cardiac fibrosis appear to be an important cause of increased morbidity and mortality in HD population, but EF monitoring is not sufficient for detecting these changes ( 1 , 17 , 23 , 26 ). Myocardial fibrosis is an important part of cardiac remodeling that leads to HF, in particular HF with a preserved EF (HFpEF).…”

“…The creation of a new functioning arteriovenous fistula (AVF) in HD patients causes an acute decrease in systemic vascular resistance and a secondary increase in cardiac output (CO) ( 13 – 15 ). The increased CO and greater venous return lead to increased left ventricular (LV) pressure and higher LV mass causing LVH ( 16 , 17 ). In general, these hemodynamic changes are clinically insignificant, however, in certain cases (such as high-flow AVF), they can cause new or worsening heart failure (HF), so-called high-output HF ( 18 , 19 ).…”

Letter by Budryte et al. regarding article “Cardiac implications of upper-arm arteriovenous fistulas: A case series”

“…Finally, we feel that Pucchio et al 1 did a great job by measuring cardiac alterations due to AVF formation. We believe, however, that the impact of AVF creation on clinical and mortality outcomes remains to be proven.…”

“…We read with considerable interest the recent Research Article by Pucchio et al, 1 presenting a prospective case series of cardiac imaging 12-months following upper-arm arterio-venous fistula (AVF) creation, demonstrating adverse changes in patients’ cardiac morphology—increases in left ventricular mass (LVM), changes of the ejection fraction (EF), and left atrial volume (LAV). Because of a scarcity of such research, it is a great essay presenting the timeline for cardiac involvement due to hemodynamic changes as a result of AVF formation.…”