Decompensated high‐output congestive heart failure in a patient with AVF and the role of right heart catheterization: A case study

Abstract

A 70-year-old Caucasian male presented 8 months postcadaveric renal transplant with slowly progressive shortness of breath, abdominal distention, and cough for a duration of a few days. Thorough evaluation found him to have severe pulmonary hypertension (PH) on echocardiogram with decompensated high-output congestive heart failure. A right heart catheterization was done, which confirmed elevated right-sided pressures and high cardiac output. The mean pulmonary artery pressure, on a Swan-Ganz catheter, improved from 37 to 30 mmHg on partial manual occlusion of his still functioning hemodialysis arteriovenous fistula. Subsequently, the patient underwent ligation of the fistula and this led to gradual improvement in his symptoms. Follow-up right heart catheterization and echocardiogram showed marked improvement and normalization of right heart pressures. We recommend that patients with arteriovenous fistula should undergo close monitoring for development of early signs and symptoms of congestive heart failure and screening for PH by echocardiography post-kidney transplant. Right heart catheterization should be considered if screening is positive. Risk and benefit of fistula closure should be weighed in face of reduced survival from PH in dialysis patients and closure should be considered in post-transplant patients.

Deceptive jugular manometry, blood colour and Po2 in the presence of an ipsilateral upper extremity arteriovenous fistula: a report of two cases

“…The occurrence of a high-output AVF causing increased cardiac output and elevated right-sided pressures has been reported. 5 In fact, a mature AVF may contribute up to 28% of resting cardiac output. 6 In both of the cases presented, a large volume of blood from the fistula with higher oxygenation returned to the RIJ vein via the right brachiocephalic vein.…”

Pulmonary Hypertension in Patients With Chronic Kidney Disease: Noninvasive Strategies for Patient Phenotyping and Risk Assessment

“…Although there is debate as to whether an AV fistula alone can lead to PH, it is clear from clinical observation and physiologic rationale (mean PA pressure ϭ cardiac output * PVR ϩ left atrial pressure) that coupling an inappropriately high cardiac output with a noncompliant, hypertrophied left heart will lead to left heart congestion, with PH being an inevitable consequence. [20][21][22] Lastly, patients with chronic left heart congestion can develop significant PVD, which may be severe enough to manifest as a clinical syndrome similar to PAH, particularly when right heart dysfunction results. Noninvasive assessment using history, physical examination, and an echo-Doppler examination forms the cornerstone of the initial evaluation of patients with CKD and suspected PH, not just because these are typically the first tests obtained, but also because much information can be gleaned from these initial tests that can guide subsequent invasive evaluations.…”

The Impact of Arteriovenous Fistulae on the Myocardium: The Impact of Creation and Ligation in the Transplant Era

“…The effects of the AVF on the heart have been described, however the effects of the fistula closure or even the flow reduction remain debatable. Multiple case reports have shown a sharp resolution of the clinical HF signs and clear improvement of symptoms following AVF surgical modification . However, this situation is described only in symptomatic patients with no evidence of improvement in asymptomatic patients with AV access and high flow.…”