Abstract: PUB078
Persistent Dyspnea in Hemodialysis: Recognizing High-Output Heart Failure from Arteriovenous Fistula Shunting
Session Information
Category: Dialysis
- 803 Dialysis: Vascular Access
Authors
- Rodriguez, Marcos Alejandro, New York City Health and Hospitals Jacobi, Bronx, New York, United States
- Jim, Belinda, New York City Health and Hospitals Jacobi, Bronx, New York, United States
- Acharya, Anjali, New York City Health and Hospitals Jacobi, Bronx, New York, United States
- Shastri, Rujul Piyush, New York City Health and Hospitals Jacobi, Bronx, New York, United States
Introduction
High-output heart failure (HOHF) secondary to an arteriovenous fistula (AVF) remains an underdiagnosed condition. It occurs when the AVF acts as a continuous shunt, diverting a significant portion of cardiac output (CO) away from the systemic circulation and triggering a cycle of neurohormonal activation, volume expansion, and progressive ventricular remodeling. Unlike classical heart failure, in which CO is reduced, HOHF is characterized by a CO >8 L/min or a cardiac index (CI) >4.0 L/min/m2.
Case Description
A 51-year-old male with a history of HTN, failed renal transplant, ESRD on hemodialysis (HD) presented with shortness of breath without missed dialysis sessions. On presentation, he was tachypneic with signs of pulmonary edema and was noted to have a large aneurysmal left arm AVF with an audible bruit and palpable thrill. Chest X-ray with vascular congestion. Laboratory studies revealed BNP of 8,300 pg/mL and troponin of 30 ng/L (range 0–22 ng/L).
The patient underwent seven HD sessions with ultrafiltration increased from 1 to 2.5 L per session, with a total fluid removal of 11 L over a 14-day hospitalization. Echocardiography with a CO of 5.38 L/min and CI of 3.7 L/min/m2, moderate left ventricular hypertrophy, grade II diastolic dysfunction, ejection fraction of 70%, and normal right ventricular size and function. Despite improvement in volume status, the patient continued to report persistent dyspnea. Additional pulmonary etiologies, including pneumonia and pulmonary embolism, were excluded by CT imaging.
Given concern for HOHF in the setting of a positive Nicoladoni-Branham sign—reflex bradycardia and increased blood pressure upon manual compression of the AVF—the patient underwent right heart catheterization, which demonstrated a CI of 4.1 L/min/m2 and moderate pulmonary hypertension with a mean pulmonary artery pressure (mPAP) of 31 mmHg. Temporary occlusion of the AVF resulted in a reduction in both pulmonary pressures and CI (mPAP 22 mmHg and CI 2.9 L/min/m2, respectively). The patient subsequently underwent AVF ligation following placement of a tunneled dialysis catheter and was discharged with complete resolution of symptoms.
Discussion
HOHF should be considered in dialysis patients with large aneurysmal AVFs who present with persistent dyspnea despite optimal volume management. Early recognition is essential to allow timely intervention and prevent progression of heart failure.