Right Ventricular Enlargement within Months of Arteriovenous Fistula Creation in 2 Hemodialysis Patients

Abstract

Surgically created arteriovenous fistulae (AVF) for hemodialysis can contribute to hemodynamic changes. We describe the cases of 2 male patients in whom new right ventricular enlargement developed after an AVF was created for hemodialysis. Patient 1 sustained high-output heart failure solely attributable to the AVF. After AVF banding and subsequent ligation, his heart failure and right ventricular enlargement resolved. In Patient 2, the AVF contributed to new-onset right ventricular enlargement, heart failure, and ascites. His severe pulmonary hypertension was caused by diastolic heart failure, diabetes mellitus, and obstructive sleep apnea. His right ventricular enlargement and heart failure symptoms did not improve after AVF ligation. We think that our report is the first to specifically correlate the echocardiographic finding of right ventricular enlargement with AVF sequelae. Clinicians who treat end-stage renal disease patients should be aware of this potential sequela of AVF creation, particularly in the upper arm. We recommend obtaining preoperative echocardiograms in all patients who will undergo upper-arm AVF creation, so that comparisons can be made postoperatively. Alternative consideration should be given to creating the AVF in the radial artery, because of less shunting and therefore less potential for right-sided heart failure and pulmonary hypertension. A multidisciplinary approach is optimal when selecting patients for AVF banding or ligation.

Improving the prognosis of patients with severely decreased glomerular filtration rate (CKD G4+): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

“…Small studies or case reports have suggested that arteriovenous fistula may lead to development of high-output HF. 54 – 58 Arteriovenous fistula creation has also been reported in small studies to worsen right ventricular hypertrophy and pulmonary hypertension 54 , 59 and found to be associated with significant right ventricular dilatation and remodeling and an increased risk for development of incident heart failure. 60 On the other hand, other studies found a stabilization of kidney function after access creation.…”

High-output cardiac failure secondary to high-output arteriovenous fistula: investigations, management and definitive treatment

“…The prevalence of pulmonary hypertension is much higher in the dialysis population and has been estimated at 17%–50% 12. However, there are a range of pathophysiological mechanisms that may explain this phenomenon, and it does not always follow that surgical fistula ligation is the correct treatment approach 13.…”

Reversible pulmonary hypertension in post -renaltransp lantation patient with longst anding arteriovenous fistula

“…В последнее время в медицинской периодиче ской литературе появился ряд подобных публика ций в формате клинических наблюдений [14][15][16][17][18][19], однако все авторы отмечают отсутствие рандомизи рованных клинических исследований.…”