AN INTERESTING CASE OF CARDIAC ARREST DURING THE CREATION OF AV FISTULA

Abstract

TYPE: Case Report TOPIC: Cardiovascular Disease INTRODUCTION: We present an intersting case of cardiac arrest due to hemodynamic compromise occurring soon after AV fistula creation. CASE PRESENTATION: 45-year-old woman with medical history of ESRD on hemodialysis and pulmonary hypertension presented for left-arm AV fistula creation. Initial parts of the procedure went uneventful. However, towards the end of procedure, 10 minutes after unclamping of the graft, patient became hypotensive and suffered from cardiac arrest secondary to pulseless ventricular tachycardia progressing to torsades. Patient received CPR and multiple defibrillator shocks, epinephrine, IV magnesium sulfate and amiodarone boluses. Blood gas showed pH of 7.05 and lactate 6.5 mmol/L. Potassium, magnesium and phosphate levels were normal. She was started on epinephrine drip for hemodynamic support and heparin drip due to concern of PE. STAT TTE showed severe LVH with LVEF of 55 to 60%, moderate pulmonary hypertension, normal RV size and function. CTA of chest did not show any evidence of pulmonary embolism therefore heparin was stopped. Patient was transferred to ICU where she remained stable and had a full neurologic recovery. DISCUSSION: AV fistula creation in patients with pre-existing pulmonary hypertension and RV dysfunction could result in increased venous return and RV preload leading to acute RV dilatation. This could cause septal shift towards the left resulting in decreased LV preload, leading to decreased cardiac output, potentially resulting in hypotension. Decreased coronary and systemic perfusion could also result in myocardial ischemia and RV failure leading to arrhythmias and death. CONCLUSIONS: Physicians should be aware of this potentially fatal acute complication of AV fistula creation. DISCLOSURE: Nothing to declare. KEYWORD: Cardiac Arrest, AV Fistula, hemodynamic effects, dialysis access, high output cardiac failure