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High Output Heart Failure Driven By Arteriovenous Fistulas In ESRD Patients
Gabriella Aponte Camacho, BS, Zachary Matthay, MD, Alexandra Sansosti, MD, Nicholas J. Morrissey, MD, Virendra I. Patel, MD, MPH.
Columbia Vagelos College of Physicians and Surgeons, NYC, NY, USA.
OBJECTIVES: Arteriovenous fistulas (AVFs) for hemodialysis access are associated with a reduction of systemic vascular resistance, leading to a compensatory rise in cardiac output. In some patients, this increased output leads to high output heart failure (HOHF), a rare but serious complication of surgical AVFs. HOHF management targets reduction of AVF blood flow through revisions (plication or banding) or ligation of the AVF. We hypothesized HOHF patients would have worse outcomes than those without HOHF when undergoing AVF surgical interventions.
METHODS: This retrospective study followed end-stage renal disease (ESRD) patients undergoing revision or ligation of their AVF. Out of 229 procedures (2020-2024), 16 were performed for HOHF. Coarsened exact matching generated a control group of 43 patients undergoing AVF interventions who had a history of heart failure but did not develop HOHF. The diagnosis of HOHF was adjudicated based on medical record reviews including symptoms of systemic congestion in the presence of elevated cardiac output (>8L/min) or cardiac index (>3.9L/min/m
2) in conjunction with cardiology documentation.
RESULTS: Patients with HOHF were younger (54.5 [49.7-60.3] vs 65.9 [56.0-77.0], p < 0.01) and had increased 30-day mortality (23.1% vs 2.30%, p = 0.04) than those without HOHF.
The groups did not differ significantly in rates of comorbidities such as coronary artery disease and diabetes.
Overall survival was reduced for the HOHF group (p = 0.05) (Figure 1).
HOHF patients had an average fistula venous outflow volume of 3,680 mL/min (2220 - 7510), cardiac output of 7.70 L/min (7.10-8.10), and cardiac index (Fick) of 4.40 (3.40-4.90). The patients equally underwent plication (n = 8) or ligation (n = 8) to manage their HOHF. There were no significant changes in cardiac parameters between patients after undergoing either procedure. Nine (56%) HOHF patients experienced qualitative symptomatic improvement in dyspnea at discharge, though only three (19%) had documented quantitative improvement at follow-up.
CONCLUSIONS: High output heart failure is a rare but morbid complication of AVFs. Surgical revisions or ligations can result in improvements, but outcomes are poor overall. More data are needed to guide management strategies and improve outcomes for patients with surgical AVFs complicated by HOHF.
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