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Among the multiple etiologies for congestive heart failure in patients with end-stage renal disease, the contribution of hemodialysis fistulas to the myocardial work load is often overlooked. We recently cared for a patient with high-output cardiac failure from an arteriovenous fistula and review the features and pathophysiology of this condition.
The use of native arteriovenous fistulas for hemodialysis access is important to the success of this form of treatment for patients with end-stage renal disease. Native fistulas have been shown to provide improved longevity and to have lower complication rates when compared to prosthetic graft fistulas. High-output cardiac failure related to hemodialysis fistulas is an uncommon complication of their usage. Two renal transplant patients who did develop this complication from large well-developed brachiocephalic arteriovenous hemodialysis fistulas are presented. Both patients underwent successful transplantation and have required fistula ligation, with subsequent resolution of their cardiac failure. Native fistulas remain the best choice for hemodialysis access, but the clinician should remain aware of the possible untoward hemodynamic effects of these fistulas.
A 19-year-old man was diagnosed with a rapidly enlarging arteriovenous malformation of the scalp and a mild degree of cardiomegaly. Operation to excise the large fistula took place under general anesthesia. Both external carotid arteries and their branches were controlled to prevent intraoperative hemorrhage, and dissection took place down to the periosteum. A split skin graft from the thigh was applied to the scalp defect. The patient recovered well with no further evidence of dyspnea or high output cardiac failure.
Hemodialysis fistulas are a cause of high-output congestive heart failure (CHF). A case is reviewed of a patient in whom surgical correction of an excessively high fistula flow led to resolution of CHF. Bradycardia induced by fistula occlusion (Nicaladoni-Branham sign) was not present, but transient occlusion did produce a marked decrease in cardiac output.
We present two cases of upper extremity vascular malformation causing a high output state in the prenatal period. One fetus responded well to transplacental digitalis treatment. Both newborns had a Kasabach-Meritt sequence including anemia and thrombocytopenia. Postpartum treatment included successful interventional occlusion of the main feeding arteries and subsequent surgical removal of the tumor.
Cardiac failure is multifactorial in causation, and the underlying physiologic mechanisms are variable, yet their renal effects have been considered more homogeneous. To investigate and compare the intrarenal hemodynamic characteristics in two experimental types (low- and high-output) of cardiac failure, renal micropuncture studies were performed in rats after myocardial infarction (MI) and arteriovenous fistula, respectively. Myocardial infarction was produced by ligation of the left main coronary artery and arteriovenous fistula by direct puncture of the aorta and inferior vena cava below the renal arteries. Pressures and interrenal and glomerular dynamics were obtained using classic micropuncture techniques. Both forms of cardiac failure were characterized by elevated left ventricular end-diastolic pressure (LVEDP), reduced mean arterial pressure, and increased cardiac mass. Left ventricular end-diastolic pressure was higher in MI rats, and effective renal plasma flow (ERPF) tended to be reduced in both forms of cardiac failure. There were no apparent differences in effective renal plasma flow between two models. In addition, single-nephron plasma flow and single-nephron glomerular filtration rate were reduced, and single-nephron filtration fraction and glomerular capillary pressure (PG) were increased in both models. These changes were associated with higher afferent and efferent arteriolar resistances and lower ultrafiltration coefficients. Despite these similarities, PG was higher in MI rats, yet LVEDP correlated directly with PG (r = 0.73; P < 0.001) and efferent arteriolar resistances (r = 0.72; P < 0.01). Therefore, although systemic arterial pressure and effective renal plasma flow were similar in both models of cardiac failure, PG was significantly higher in MI rats with higher LVEDP than in arteriovenous fistula rats.(ABSTRACT TRUNCATED AT 250 WORDS)
BACKGROUND: Vitamin B1 deficiency (beriberi) is very uncommon in France. It leads to high output cardiac failure totally different from the situation observed in alcoholic patients. We report a typical case of cardiac beriberi. CASE REPORT: The patient was referred for dyspnea with high output cardiac failure. Echocardiography evidenced severe pulmonary hypertension and high cardiac output. The more common causes of heart failure were ruled out. The dietary habits of the patient (suggested beriberi which was confirmed by the low serum thiamin and therapeutic test with vitamin B1. DISCUSSION: High output cardiac failure should suggest possible Shoshin beriberi, particularly in subjects with imported dietary habits living in a precarious socioeconomic situation.
The authors describe a novel approach to the management of high-output heart failure secondary to an intracranial high-flow dural arteriovenous fistula (DAVF) by using extracorporeal membrane oxygenation (ECMO). To the best of the authors' knowledge, this represents the first report of an embolization performed in conjunction with the use of an ECMO circuit and the first report in which an ECMO cannula was used for intraarterial access for cerebral angiography. A 2-day-old girl presented with severe, high-output heart failure secondary to a high-flow intracranial DAVF. The patient was neurologically intact and no brain parenchymal abnormalities were revealed on computerized tomography scanning of the head, but she suffered severe heart failure, pulmonary hypertension, and liver and renal dysfunction. The patient underwent three endovascular embolization procedures involving coils and liquid embolic agents. Despite a decrease in the DAVF flow, the patient had only transient improvement in her pulmonary hypertension, and venoarterial ECMO therapy was instituted. Another embolization was performed while the patient was receiving ECMO therapy. Her cardiovascular status improved, she was weaned from ECMO, and she was eventually discharged home to her family. Extracorporeal membrane oxygenation can be used to sustain severely ill neonates with high-output heart failure secondary to intracranial AVFs. Embolization can be performed while the patient is receiving ECMO therapy.
When utilizing the intravascular double-indicator dilution technique to measure extravascular lung water, blood flow may be so high that diffusion equilibrium of the diffusible indicator fails to occur and the water distribution space is underestimated during the first 7 days after thermal injury. We serially measured cardiac index and lung water in five severely burned patients (mean age 24 years, range 18 to 33 years; mean burn size 56% total body surface, range 43% to 80%) by a rebreathing method utilizing two gases of differing solubility and by the thermal-indocyanine green dye (ICG) double-indicator dilution technique. Rebreathing lung water, determined by a time- and blood flow-insensitive method, increased significantly over the study period, from 6.6 ml/kg on admission to the hospital 11.3 ml/kg on postburn day 6 (+70%, P less than 0.01). Thermal-ICG lung water decreased slightly as blood flow rose. Rebreathing lung water correlated with clinical data in a patient with pulmonary edema, while thermal-ICG lung water changed in the opposite direction. Our data suggest that the thermal-ICG technique may be diffusion limited by short transit times at the high flows characteristic of burned and other critically ill patients with hyperdynamic circulations. Additionally, segmented redistribution of pulmonary blood flow known to occur in burn patients may contribute to underestimation of lung water.
Pulmonary gas exchange was evaluated in 10 anesthetized mechanically ventilated dogs. Cardiac output (QT) was increased approximately 50% by opening peripheral arteriovenous fistulas. With both lungs ventilated, increasing QT increased mixed venous O2 both pressure (PO2) and pulmonary arterial pressure, but neither shunt fraction nor the distribution of ventilation-perfusion was consistently altered. During left lung atelectasis, increasing QT again increased mixed venous PO2 and pulmonary arterial pressure, but two different responses in shunt-like perfusion were measured. In four dogs, left lung atelectasis caused a shunt fraction of 46 +/- 6% that was not changed by high QT (P greater than 0.05). In six dogs, atelectasis caused a shunt fraction of 24 +/- 3% during normal QT that increased to 42 +/- 2% during high QT (P less than 0.001). Dogs whose shunt fraction during atelectasis was high and unchanged by QT had lower arterial pH (7.24 +/- 0.03) than dogs whose shunt fraction was initially lower and was increased with QT (7.36 +/- 0.02) (P less than 0.01). We conclude that increased QT can worsen shunt flow during lobar atelectasis when hypoxic vasoconstriction has been effective in limiting perfusion to the collapsed region at normal levels of QT.
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1. Mean arterial pressure, cardiac output (electromagnetic flow-meter) and regional blood flows (15 micrometer radioactive microspheres) were measured repeatedly in eight dogs receiving a salt and water load after renal mass reduction as well as in six control animals. 2. As previously observed, hypertension developed in the salt-loaded dogs with an initial increase in cardiac output followed by a secondary rise in total peripheral resistance. 3. Much of the early increase in cardiac output was distributed to the skeletal muscle vascular bed. 4. Total peripheral resistance changes did not reflect the resistance of individual vascular beds in the early stages of salt and water load hypertension; indeed, resistance in the muscle vascular bed was decreased and that in the splanchnic area and the bone increased on the first day of salt and water load when total peripheral resistance was unchanged.
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