Abstract
Introduction: High-output heart failure (HF) develops in the setting of excessive cardiac output. Case Presentation: 65-year-old male with HF (EF 40%), severe right ventricular dysfunction, and emphysema presented with dyspnea and anasarca. On admission, physical examination showed a BP 97/66mmHg, heart rate 109bpm, temperature 97.2F, respiratory rate of 19rpm, 93% on 2-Liters of oxygen. Jugular venous pressure was 20 cm H20 with large V waves. The rhythm was irregular, with a loud second heart sound, audible third heart sound, parasternal heave, and left lower sternal border murmur. Lung exam demonstrated basilar crackles and prolonged expiratory phase. The abdomen was distended with a pulsatile liver and the lower extremities were cool with 3+ pitting edema. There was an audible bruit with thrill at the right groin. Laboratory testing showed sodium=123mEq/L, creatinine=1.25mg/dL, bilirubin=2.2, ALT=135U/L, AST=146u/L, troponin-I=0.097ng/mL, BNP=1528pg/mL. CT and VQ scan were negative for acute/chronic pulmonary embolism. Lower extremity Doppler ultrasound revealed a right common femoral arteriovenous (AV) fistula (Fig.1). After diuretics and milrinone, a left heart catheterization demonstrated known three vessel disease, but without limitations in instant flow reserve. Right heart catheterization demonstrated RA=15mmHg, RV=50/16mmHg, PA=50/24(34)mmHg, PCWP=11mmHg, CO=5.4L/min, PVR=4.25WU, after which the fistula was ligated. On post-op day 2, repeat hemodynamics off inotropes showed an RA=4mmHg, PA=40/18mmHg, PCWP=18 mmHg, CO=4.4L/min and normalization of end-organ function. He was maximized on GDMT. Echocardiogram 5 months later showed improvement of RV function and he was able to go back to work with minimal symptoms. Conclusion: AV fistulas can lead to high-output HF if undiagnosed. A multidisciplinary approach and comprehensive hemodynamic assessment proved essential in allowing improvement of symptoms and resulting outcomes.
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