Renal arteriovenous fistula masquerading as severe valvar heart disease.

Abstract

SUMMARY Two patients with renal arteriovenous fistulae are described, who presented in high output failure. Murmurs were detected in these patients on routine physical examination years before, and when cardiac failure ensued they were assumed to have decompensated valvar heart disease. Full investigation revealed the arteriovenous fistulae and both patients made a good recovery after surgical ligation.An arteriovenous fistula occurring after abdominal surgery is uncommon and may escape detection, unless the characteristic murmur is sought and angiographic studies performed. We report 2 patients in whom renal arteriovenous fistulae followed nephrectomy and resulted in signs and symptoms consistent with severe valvar heart disease. Case reports CASE 1A 61-year-old woman had a 10-year past history of dyspnoea on exertion. Six years previously a heart murmur had been detected on routine examination.In the following year hypertension was noted, and treatment was started with salt restriction, diuretic, and methyldopa. Four months before admission she developed congestive heart failure and was started on digoxin, but despite this she presented in pulmonary oedema one month later. There was no past history of rheumatism or coronary heart disease, but she had had multiple abdominal surgical procedures, including a right nephrectomy in 1960 for renal tuberculosis and nephrolithiasis.Physical examtion showed a blood pressure of 160/60 mmHg, with a regular pulse of 80 per minute. The carotid upstroke was brisk and full.Lungs were clear. A hyperdynamic apical impulse was palpable in the sixth left intercostal space. A systolic thrill was present, maximal at the lower left sternal border. On auscultation, the first sound was Received for publication 26 January 1978 normal, the second sound narrowly split, and aortic closure slightly accentuated. A harsh grade 3/6 midsystolic murmur was loudest in the second right intercostal space; a grade 4/6 continuous murmur was heard over the entire chest posteriorly loudest over the right costovertebral angle, and in the right upper abdominal quadrant anteriorly where a continuous thrill was present. Loud third and fourth sound gallops were also noted. There was no hepatosplenomegaly. Mild oedema of the ankles was present.The electrocardiogram showed normal sinus rhythm, left atrial abnormality, and increased QRS voltages denoting left ventricular hypertrophy. Chest x-ray films showed cardiomegaly with left ventricular and left atrial enlargement and prominent pulmonary vascular markings.Cardiac catheterisation showed raised right heart pressures. No left or right shunt was detected with the hydrogen electrode. The cardiac output was 10-75 1/min, with cardiac index 6-60 1/min per M2.There was a wide aortic pulse pressure of 120 mmHg. Left ventricular end-diastolic pressure was raised to 32 mmHg. There was no gradient across the aortic valve. Left ventriculogram showed normal contractility with minimal mitral regurgitation. Ascending aortography showed no aortic regurgitation. The co...