High flow arteriovenous fistula: a cause of reversible heart failure in hemodialysis

Jiménez Mayor, Elena; González Sanchidrián, Silvia; Silva Cerpa, Miguel Ángel

doi:10.1016/j.medcle.2024.04.021

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Its prevalence is not well defined and often underdiagnosed.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>The existence of a hyperfunctioning AVF, with high arterial flow (Qa), triggers problems such as cardiac overload, cardiopulmonary recirculation and vascular access (VA) anomalies that lead to high morbidity and mortality. Early detection and treatment are essential to reverse heart failure.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>We report the case of a 61-year-old woman with hypertension, dyslipidaemia and renal disease secondary to focal segmental glomerulosclerosis who started haemodialysis through a left humeral-cephalic AVF in 2020. Six months later, the patient reported moderate dyspnoea and orthopnoea.The echocardiogram showed a hypertrophic and dilated left ventricle with generalised hypokinesia and an LV ejection fraction (LVEF) of 31%. She had no previous heart disease (pre-dialysis LVEF 60%). Anaemia, pneumological causes were ruled out. Normovolaemia. Treatment with sacubitril/valsartan, nebivolol and eplerenone was started without improvement, and she was temporarily contraindicated for renal transplantation. The VA ultrasound showed an approximate flow of 3 L. Echocardiographic cardiac output (CO) suggested high flow, decreasing from 9.3 L/min to 6.7 L/min after manual AVF occlusion. Right heart catheterisation confirmed these findings and the presence of pulmonary hypertension. Cardiac MRI showed non-ischaemic dilated cardiomyopathy, asymmetric septal hypertrophy and biventricular dysfunction; no fibrosis or necrosis.With the diagnosis of HOHF, ligation of the AVF was performed. The presence of aneurysms and tortuosity of the AVF prevented a banding-type partial closure. Four months later, the patient showed significant clinical and echocardiographic improvement, with LVEF recovery to 65%, and was again included on the kidney transplant list. At 10 months she reached an LVEF of 68%.HOHF is defined as the concurrence of signs and symptoms of systemic congestion in the presence of high CO (>8 l/min) or high cardiac index (>3.9 l/min/m2 in adults).<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> The causes of HOHF are simplified into two categories: increased blood demand due to hypermetabolism or a shunt in the arteriolar-capillary bed that decreases systemic vascular resistance. In AVF-related high CO, vascular flow functions as a parallel circuit between the AVF and the peripheral circulation, leading to a reduction in systemic vascular resistance and an increase in venous return. As a compensatory response, CO increases and the cycle perpetuates: as CO increases, venous return increases. AVF can increase CO by 10–25%, diastolic ventricular pressure by 4% and the incidence of pulmonary hypertension by 40%, all in the context of an elevated Qa.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The Spanish Vascular Access Guidelines define high-flow AVF as an AVF with a Qa >1-1.5 L/min and cardiopulmonary recirculation >20%.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Risk factors for developing AVF-associated HOHF include: a proximal AVF, male sex, previous surgery on the vascular access, Qa > 2.0 L/min and a Qa/CO ratio >0.3.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Although controversial, these factors have been postulated as decompensating causes in patients with poor cardiac reserve or pre-existing heart disease.<a class="elsevierStyleCrossRefs" href="#bib0005">1,4</a>Although some series report a low frequency of HOHF due to high Qa AVF, there is sufficient evidence showing regression of cardiac indices after ligation or reduction in the Qa of the AVF.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> The therapeutic approach is controversial, although different series describe surgical techniques to reduce flow without loss of vascular access, this is not always possible, and there are no studies that show one technique to be superior to another.In our experience, AVF-associated HOHF is a serious and reversible complication in haemodialysis patients. Although preserving the VA could be a priority whenever the clinical situation allows it, failure to treat early could compromise kidney transplantation and lead to a major life-threatening cardiac complication.It would be useful to create predictive models to detect hyperflow patients who may eventually develop HOHF. Our case is an example of the rapid and significant reversibility of cardiac function with early intervention.Ethical considerationsThe study complied with the respective ethical considerations and the principles set out in the Declaration of Helsinki. The authors declare that they have the informed consent of the study subject and respect the patient's right to privacy. No experiments were performed on humans or animals.FundingThe authors of the paper claim to have received no funding for the study.Conflict of interestThis manuscript has not been previously published and is not under review in another journal. The authors declare that they have no conflict of interest. The intellectual property rights of the work and the right to authorise the reproduction of data in other publications are granted to Medicina Clínica." "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0001" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 3 => array:2 [ "identificador" => "xack783898" "titulo" => "Acknowledgements" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "High output cardiac failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I.S. Anand" 1 => "V.G. Florea" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11936-001-0070-1" "Revista" => array:7 [ "tituloSerie" => "Curr Treat Options Cardiovasc Med" "fecha" => "2001" "volumen" => "3" "numero" => "2" "paginaInicial" => "151" "paginaFinal" => "159" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11242561" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of high flow arteriovenous fistula on cardiac function in hemodialysis patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.A. Saleh" 1 => "W.M. El Kilany" 2 => "V.W. Keddis" 3 => "T.W. El Said" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ehj.2018.10.007" "Revista" => array:7 [ "tituloSerie" => "Egypt Heart J" "fecha" => "2018" "volumen" => "70" "numero" => "4" "paginaInicial" => "337" "paginaFinal" => "341" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30591752" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spanish clinical guidelines on vascular access for haemodialysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Ibeas" 1 => "R. Roca-Tey" 2 => "J. Vallespín" 3 => "T. Moreno" 4 => "G. Moñux" 5 => "A. Martí-Monrós" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.nefro.2017.11.004" "Revista" => array:6 [ "tituloSerie" => "Nefrologia" "fecha" => "2017" "volumen" => "37" "numero" => "Suppl 1" "paginaInicial" => "1" "paginaFinal" => "191" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The relationship between the flow of arteriovenous fistula and cardiac output in haemodialysis patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. Basile" 1 => "C. Lomonte" 2 => "L. Vernaglione" 3 => "F. Casucci" 4 => "M. Antonelli" 5 => "N. Losurdo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ndt/gfm549" "Revista" => array:7 [ "tituloSerie" => "Nephrol Dial Transplant" "fecha" => "2008" "volumen" => "23" "numero" => "1" "paginaInicial" => "282" "paginaFinal" => "287" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17942475" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Regression of left ventricular hypertrophy after arteriovenous fistula closure in renal transplant recipients: a long-term follow-up" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P. Unger" 1 => "S. Velez-Roa" 2 => "K.M. Wissing" 3 => "A.D. Hoang" 4 => "P. van de Borne" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1600-6143.2004.00608.x" "Revista" => array:7 [ "tituloSerie" => "Am J Transplant" "fecha" => "2004" "volumen" => "4" "numero" => "12" "paginaInicial" => "2038" "paginaFinal" => "2044" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15575907" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack783898" "titulo" => "Acknowledgements" "texto" => "We want to thank Dr. José Luis Merino and Dr. Deira for their experience and contributions to the case." 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Vol. 163. Issue 8.

Pages 423-424 (October 2024)

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