Access High output heart failure in patients with upper arm A‐V fistulae: Diagnosis and treatment

Abstract

Purpose: Arteriovenous fistula (AVF) is the preferred blood access for hemodialysis due to its longevity and resistance to infection. Little attention is given to the long‐term hemodynamic consequences of large left‐to‐right shunts, particularly in patients with brachial artery fistulae. Materials and Methods: We describe 9 patients (8 on dialysis, 1 post‐transplant), aged 25–73, who developed clinical heart failure, primarily due to large, upper arm AVFs. Results: 4/9 had access flows in excess of 2 liters/min, assessed by blood temperature monitoring. 6/9 had cardiac output measured by right heart catheterization, before and after shunt compression. One also underwent left heart catheterization with ventriculography. 3/9 had surgical reduction of the fistula, either by banding or by serial interposition of small caliber GoreTex graft. In 2/9 the shunt was ligated. One patient had heart failure in association with 2 large, upper arm AVFs, one of which was ligated. After years of improved cardiac symptoms, heart failure recurred in association with marked hypertrophy of his remaining AVF. Resting cardiac output in this patient was in excess of 11 liters/min. 2/9 experienced acute onset of heart failure within 1–3 days of angioplasty of a venous stenosis. One of these, with very poor baseline cardiac function, expired. Surgical revision or ligation was accompanied by clinical improvement in the 5 patients so treated. One of these expired of a stroke after two months of cardiac improvement. Conclusion: High output heart failure is under‐diagnosed in dialysis patients. Patients with large upper arm shunts are particularly at risk. Access flow should be assessed regularly and those with outputs >1.5 liters/min should be monitored closely for development of heart failure. Surgical correction is beneficial and indicated in symptomatic patients. Patient number Age/Sex Access type Years with access Flow (liters/min) Change CO (liters/min) Rx Outcome 1 37/M AVF 8 >2 1.7 Reduction Improved 2 26/M AVF 5 >2 2.4 Band Improved 3 73/M AVF 3 >2 1.5 Reduction Improved 4 45/M AVF 10 n/a 3.2 Reduction Improved 5 65/M AVF 4 >2 2.8 Band Improved 6 57/F AVG 4 1.2 1.8 7 39/F AVF 2 n/a n/a Ligate Improved 8 66/M AVG 0.3 0.7 n/a Ligate Improved 9 69/F AVF 0.25 n/a n/a Expired