A Formidable Fistula: Improved High Output Heart Failure After Fistula Closure
Document Type
Article
Abstract
Background: Heart failure can be classified into either preserved or reduced ejection fraction and is generally accompanied by decreased cardiac output and increased systemic vascular resistance. In some instances, signs of heart failure can be seen with low systemic vascular resistance and a compensatory high cardiac output.
Case: A 45 year old male with previous ESRD status post renal transplant and persistent arteriovenous fistula, presented with shortness of breath, abdominal distension, and lower extremity swelling. He had an abdominal incisional hernia as a result of complications from his kidney transplant and was evaluated for hernia repair due to increased distension and pain. Labs were unremarkable, and an ultrasound of his abdomen showed a large amount of ascites, which required multiple paracentesis. Right heart catheterization revealed high cardiac output, elevated pulmonary capillary wedge pressure and right atrial pressure. A transvenous liver biopsy was also performed, revealing changes compatible with chronic venous outflow obstruction with foci of bridging fibrosis. He underwent ligation and excision of his upper extremity fistula, which markedly improved his symptoms, and he no longer needed recurrent paracentesis.
Decision-making: The patient’s symptoms were attributed to high output heart failure from peripheral shunting. His high output heart failure was leading to elevated right sided pressures and congestion in the hepatic vasculature. This ultimately leads to fibrosis and portal hypertension preceding ascites development. In reversing the fistula and therefore restoring adequate systemic vascular resistance, the effective circulatory volume is increased. This increases blood flow to crucial organs such as the kidney which then normalizes the neurohormonal feedback such as the renin-angiotensin-aldosterone system and vasopressin concentrations. This then allows for natriuresis, normalizing pressures in the central venous system and subsequent symptomatic improvement.
Conclusion: Reversal of an arteriovenous fistula in high output heart failure can greatly improve symptoms and quality of life.
First Page
2671
DOI
10.1016/S0735-1097(22)03662-2
Publication Date
3-8-2022
Recommended Citation
Henstenburg B, Patel ZJ, George AJ, Sheikh T, Jacobs LE. A FORMIDABLE FISTULA: IMPROVED HIGH OUTPUT HEART FAILURE AFTER FISTULA CLOSURE. Journal of the American College of Cardiology. 2022 Mar 8;79(9_Supplement):2671-.