Cardiac remodeling after reduction of high-flow arteriovenous fistulas in end-stage renal disease

Abstract

In patients with end-stage renal disease, excessive blood flow through an arteriovenous fistula (AVF) may lead to volume overload-induced cardiac remodeling and heart failure. It is unclear which patients with hyperfunctional AVF may benefit from AVF reduction or ligation. The indication for the procedure is often based on AVF flow. Because cardiac remodeling is driven by increased venous return, which is equivalent to cardiac output, we hypothesized that an elevated cardiac index (CI) might better identify subjects with reverse remodeling after AVF reduction. Thirty patients (age 52±12 years, 73% male) with AVF flow ⩾1.5 l min(-1) underwent comprehensive echocardiographic evaluations before and after AVF reduction. At baseline, 16 patients had a normal CI (2.5-3.8 l min(-1) m(-2)) and 14 had a high CI (4.0-6.0 l min(-1) m(-2)). A left ventricular end-diastolic diameter decrease after operation was predicted by elevated baseline CI (P<0.01), but not elevated AVF flow (P=0.07). There was a significant decrease in CI, left ventricular mass, left atrial and right ventricular diameter and pulmonary systolic pressure in the high CI group but not in the normal CI group. After AVF reduction, systemic vascular resistance decreased in the normal CI group, whereas it did not change in the high CI group. In conclusion, reduction of high-flow AVF leads to reverse cardiac remodeling but only in patients with elevated CI. The variability of the response of systemic vascular resistance to AVF flow may explain this observation. Increased CI but not increased AVF flow may better determine candidates for AVF reduction.

NT-pro-BNP as marker for cardiac strain that may be caused by high-output arteriovenous shunting in a haemodialysis patient. A case report

“…3b). The return flow has to be put in relation to the size of the patient and the total cardiac output [29]. The present case supports repeated routine measurement of pre-dialysis NT-proBNP as it may help to detect progressive cardiac strain better and relate it to AVF flow changes.…”

Arteriovenous Fistula Creation and Estimated Glomerular Filtration Rate Decline in Advanced CKD: A Matched Cohort Study

“…This high left-to-right shunt leads to cardiac volume overload, which in turn leads to high cardiac demand, cardiac hypertrophy and ultimately classical high output heart failure 39 . Ligation or reduction of AVF in patients with high-flow access may lead to reduction in left ventricular enddiastolic diameter 40 . Moreover, AVF is associated with pulmonary hypertension, a progressive and potentially fatal cardiopulmonary condition that is improved by ligation of AVF 41 .…”

Contemporary management of arteriovenous hemodialysis fistula aneurysms

“…However, it is unclear what effect AVF reduction has on heart remodelling. In a published series of thirty patients with AVF fl ow ≥ 1.5 L/min treated by aneurysmorrhaphy with external mesh prosthesis, Wohlfahrt et al [35] evaluated the effect of reduction of AVF fl ow on cardiac remodelling. Reverse cardiac remodelling (decreased LV end-diastolic diameter and mass, left atrial and right ventricular diameter and pulmonary pressure) was observed only in patients with elevated cardiac index (≥ 3.9 L/min/ m 2 ).…”

“…While several studies have reported on the treatment of high fl ow vascular access, only a few of them assess high fl ow vascular access in the presence of an aneurysm. Aneurysmorrhaphy with external mesh can signifi cantly reduce fl ow rates [35,43] and precipitate reverse cardiac remodelling with fl ow rates ≥ 1.5 L/min in patients with elevated cardiac index (≥ 3.9 L/min/m 2 ) [35]. However, aneurysmorrhaphy has proven unsuccessful with fl ow rates >2.5 L/min [19].…”