High-Output Cardiac Failure due to Excessive Shunting in a Hemodialysis Access Fistula: An Easily Overlooked Diagnosis

Abstract

A dialysis arteriovenous fistula caused life-threatening high-output cardiac failure in a 66-year-old patient. Excessive shunting through the dialysis fistula was demonstrated by invasive measurement of cardiac output, systemic arterial blood pressure, systemic vascular resistance, and oxygen consumption before and after temporary occlusion of the dialysis fistula. Noninvasive echo-cardiographic evaluation of the influence of fistula compression on cardiac output and noninvasive duplex measurement of the fistula flow also confirmed the diagnosis. Following surgical closure of the fistula, the patient’s condition improved, and signs of congestive heart failure subsided. High-output cardiac failure is a rare complication of dialysis arteriovenous fistulas. The diagnosis may remain unrecognized for longer periods. Noninvasive methods for estimation of the hemodynamic importance of a fistula may be of help in the establishment of the proper diagnosis.

Percutaneous Femoral Arteriovenous Shunt Creation for Advanced Chronic Obstructive Pulmonary Disease

“…Fifteen patients were enrolled between July 19, 2007, and September 18,2008. During this time period, 1 to 3 procedures were performed per month, with the exception of 6 months when no procedures were performed.…”

“…15 Indeed, a reduction in left ventricular size and volume, along with impaired left ventricular diastolic filling, in patients with COPD has been reported, 16 perhaps the result of diminished right heart function and left ventricular underfilling because of static hyperinflation. 17 Thus, in theory, AVS creation may improve left ventricular filling and performance; however, heart failure because of arteriovenous fistula formation has been reported, 18,19 and despite the reduction in systemic vascular resistance, an increase in left ventricular stroke work after AVS creation has been shown. 8 Four patients in our study developed right heart failure.…”

Arteriovenous Fistula Toxicity

“…Diastolic dysfunction and CHF may occur [12]. Classic high output failure has been described in numerous case reports [13,14], but is very likely underrecognized [15]. It should be considered in any dialysis patient presenting with signs or symptoms of CHF, but without obvious volume overload.…”

Fistula Diameter Correlates with Echocardiographic Characteristics in Stable Hemodialysis Patients

“…In general, one would expect to see an impact of fistula flow on cardiac output and left ventricular dimensions. In fact, this would probably apply to a population with more heterogeneous flow characteristics, as found by others (5,7,9,12,20). Another explanation could be the difficulty of achieving adequate measurements of the flow, since flow measurements can only be made in locations with laminar flow and free from disturbance.…”