Early echocardiographic modifications after flow reduction by proximal radial artery ligation in patients with high-output heart failure due to high-flow forearm arteriovenous fistula.

BACKGROUND: Arteriovenous fistula (AVF) for haemodialysis (HD) induces a volume/pressure overload which impairs bi-ventricular function and increases systolic pulmonary arterial pressure (PAPS) and left ventricular mass (LVM). In the presence of high blood flow (Qa) AVF (> 1.5 L/min/1.73 m2) and cardio-pulmonary recirculation (>20%), high-output congestive heart failure (CHF) may occur and AVF flow reduction is recommended. Proximal Radial Artery Ligation (PRAL) is an effective technique for distal radio-cephalic (RC) AVF flow reduction. METHODS: we evaluated six HD and four transplant patients with high-flow RC AVF and symptoms of CHF who underwent PRAL. We compared echocardiographic (ECHO) findings before (T0) and 1 and 6 months (T1,T6) after PRAL. Preoperative ECHO was performed before (T0b) and after AVF anastomosis manual compression (T0c). RESULTS: At T1 AVF flow reduction rate was 58.4% ± 13% and 80% of patients reported improved CHF symptoms. ECHO data showed an improvement of tricuspid annular plane systolic excursion (TAPSE) at T1 (p = 0.03) and a reduction of PAPS at T6 (p = 0.04). TAPSE improved after AVF anastomosis compression during preoperative ECHO (p = 0.03). Delta of TAPSE at the dynamic manoeuvre at T0 directly correlated with early (1 month after PRAL, p = 0.01) and late (6 months after PRAL, p = 0.04) deltas of TAPSE. CONCLUSIONS: AVF flow reduction after PRAL induces immediate regression of CHF symptoms, early improvement of TAPSE and late improvement of PAPS, suggesting a prevalent right sections involvement in CHF. Preoperative TAPSE modification after AVF anastomosis compression could represent a useful evaluation tool to determine which patients would benefit of PRAL.

Features of high flow access in the elderly.

INTRODUCTION: The number of elderly hemodialysis patients continues to grow. The aim of this study was to investigate differences in elderly high flow access patients compared with middle-aged and young patients. METHODS: We performed a retrospective study to determine the characteristics of elderly patients (aged >60 years) following blood flow suppression procedures. Preoperative and postoperative data from 177 patients who underwent blood flow suppression procedures and 73 patients who underwent procedures for run-off vein ligation and subcutaneous fixation of the superficial artery were compared. RESULTS: A high proportion of young (aged 20-40 years) and middle-aged (aged 41-60 years) patients met the criteria for blood flow suppression procedures (flow volume 1500 mL/min, flow volume/cardiac output 35%), whereas a high proportion of elderly patients did not. Moreover, heart strain could evidently be caused even with low flow volume. In elderly patients, a tricuspid regurgitation pressure gradient and right heart strain were observed more frequently. CONCLUSION: Elderly patients who underwent blood flow suppression procedures or subcutaneous fixation of the superficial artery exhibited lower flow volume, and the effects of high flow access in elderly patients depend on the nature of vascular changes. Ultimately, the underlying conditions and hemodynamics of each patient must be determined on an individual basis.

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

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.

Outcomes of blood flow suppression methods of treating high flow access in hemodialysis patients with arteriovenous fistula.

PURPOSE: A high flow access (HFA) may cause heart failure in patients with an arteriovenous fistula (AVF) undergoing hemodialysis (HD) and is associated with poor prognosis. There are a variety of blood flow suppression techniques for treating HFA; however, the therapeutic outcome is still unclear. METHODS: The following three different blood flow suppression methods were performed on 74 patients with HFA: proximal artery banding with distal artery ligation (A-ban with A-lig: 12 cases); shunt vein banding (V-ban: 37 cases); and anastoplasty (Ana: 25 cases). RESULTS: There were no differences in the sex or mean age or duration of HD between the treatment groups. The A-ban with A-lig method was mainly selected for patients with a distal AVF and the anastoplasty method was selected most often for patients with a cubital AVF. The techniques were equally effective in reducing flow volume (FV) and the FV/cardiac output ratio (Flow/CO) to target levels, and clinical symptoms improved in all patients. The rates of HFA recurrence and AVF occlusion were significantly higher in the V-ban group (18.9% and 24.3%, respectively). A small proportion of patients in each treatment group developed a postoperative infection. CONCLUSIONS: Each method proved to be an effective means of treating HFA. The choice of surgical method should be informed by the type of vascular access; however, the A-ban with A-lig and Ana methods appear to achieve clinically significant reductions in FV and have lower rates of HFA recurrence and AVF occlusion.

Fetoscopic laser photocoagulation of feeding vessels to a large placental chorioangioma following fetal deterioration after amnioreduction.

Large placental chorioangiomas (>4 cm) can precipitate severe polyhydramnios, fetal anemia, growth restriction, high-output cardiac failure, hydrops, and fetal demise. We report a case of a large chorioangioma that was treated in a stepwise fashion with amnioreduction to ameliorate maternal discomfort, followed by fetoscopic laser ablation of the feeding vessels after rapid evolution of heart failure. Although amnioreduction was helpful in improving maternal symptoms, we suspect that the drop in intrauterine pressure from the amniotic fluid decompression may have resulted in increased tumor perfusion, thereby promoting fetal deterioration due to a 'steal' phenomenon. Close scrutiny of the fetal status via ultrasound is required, particularly if amnioreduction is necessary, and definitive treatment should be considered once early signs of heart failure develop. Fetoscopic laser ablation of the feeding vessels is a feasible definitive treatment of a large chorioangioma in cases in which perfusion of the tumor is via a superficial nonterminus umbilical artery. Future reports should describe the anatomy of the blood supply to the chorioangioma, in the hopes that further guidelines for surgical candidacy may be established.

General anesthesia in a patient with Parkes Weber syndrome with high-output cardiac failure due to multiple arteriovenous fistulas complicated by severe aortic regurgitation.

Parkes Weber syndrome is a rare disease characterized by overgrowth of an extremity linked to the presence of an arteriovenous malformation with multiple arteriovenous fistulas (AVFs). We report a patient with Parkes Weber syndrome with high-output cardiac failure due to multiple AVFs complicated by severe aortic regurgitation (AR) who required surgical treatment for AVFs. Division of the left deep femoral artery and banding of the left superficial femoral artery were performed. Such procedures can cause aggravation of AR and left ventricular failure due to the sudden increase in cardiac afterload. Pulmonary artery pressure, mixed venous oxygen saturation and cardiac index monitored by a thermodilution catheter, and a transesophageal echocardiography were useful in evaluating the effect of the surgical procedure and resultant acute increase in cardiac afterload on cardiac output and left ventricular function.

Revision using distal inflow for treatment of heart failure secondary to arteriovenous fistula for hemodialysis.

In patients on hemodialysis, cardiovascular disease can be precipitated or worsened by the presence of a high flow arteriovenous fistula. Fistula closure and banding are the traditional treatment methods of dialysis associated high output cardiac failure. We present a case of fistula-related high output cardiac failure treated by revision using distal inflow (RUDI).

Treatment of high-output coronary artery fistula by off-pump coronary artery bypass grafting and ligation of fistula.

Coronary artery fistulas (CAF) are uncommon entities often associated with myocardial ischemia and high output failure. Surgical options include ligation of the fistula, with/without simultaneous coronary artery bypass grafting (CABG). We report a case of left main coronary artery (LMCA) fistula to the coronary sinus (CS), which was associated with high-output bi-ventricular failure, and moderate mitral (MR) and tricuspid regurgitation (TR), related to the volume overload and annular dilatation. This was tackled elegantly by off-pump CABG to protect the territories supplied by the LMCA, followed by ligation of the fistula. This resulted in resolution of the MR and TR. Intraoperative transesophageal echocardiogram (TEE) greatly facilitated the surgical treatment, by identifying the origin and the draining points for the fistula, and aided in the quantification of MR and TR, which had regressed sufficiently at the end of the procedure and did not require surgical correction. This article outlines the importance of multi-disciplinary treatment approach for this complex condition.

Bevacizumab reverses need for liver transplantation in hereditary hemorrhagic telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease characterized by mucocutaneous and visceral telangiectasia. Hepatic involvement with vascular malformations may lead to portal hypertension, biliary ischemia, and high-output cardiac failure. Liver transplantation is indicated for life-threatening disease but carries significant risk from surgery and chronic immunosuppression. We report a case of a 47-year-old woman with HHT successfully treated with the vascular endothelial growth factor (VEGF) antibody bevacizumab. The patient was referred for consideration of liver transplantation because of hepatic HHT leading to high-output cardiac failure, diuretic resistant ascites, cholestasis, and malnutrition. As she was considered a high-risk candidate for transplantation, she underwent 6 courses of bevacizumab (5 mg/kg) over 12 weeks. A dramatic improvement in her clinical state was observed after 3 months with reversal of cholestasis, resolution of cardiac failure and ascites, and improvement in nutritional status with a 10% dry weight increase. Treatment induced a marked reduction in liver vascularity and halving of her liver volume from 4807 to 2269 mL over 6 months. This was associated with normalization of her cardiac output from 10.2 to 5.1 L/minute. Correspondingly, she ceased diuretic medications, returned to full-time work, and was delisted as a transplant candidate. She remains well 6 months after completing treatment. In conclusion, antagonism of VEGF receptors led to a dramatic regression of hepatic vascular malformations and reversal of high-output cardiac failure and complications of portal hypertension in this patient with HHT. Bevacizumab may potentially alleviate the need for liver transplantation in this group of patients.

Inflow reduction by distalization of anastomosis treats efficiently high-inflow high-cardiac output vascular access for hemodialysis.

The arteriovenous fistula used for vascular access for hemodialysis may contribute to development of congestive heart failure. Theses patients can present with frequent episodes of congestive hear failure. Traditional management of high-inflow, a high-cardiac-output fistula generally involves either closure or banding. Although high-output state can be controlled, the lifeline of the patient is lost. We describe a series of 17 hemodialysis patients (10 men and 7 women) in whom a novel inflow reduction method was employed. All patients had symptoms of heart failure (15 brachiocephalic fistulas and two brachioaxillary bypass grafts) and a fistula inflow rate above 1600 ml/min. The inflow reduction procedure included ligation of the brachial anastomosis and reconstruction of the fistula by using an expanded polytetrafluoroethylene (Gore-Tex Intering) vascular graft in a bypass from the radial artery. The mean (+/- SD) time between fistula creation and the inflow reduction procedure was 30 +/- 17 months. The mean access inflow rate decreased significantly after the inflow reduction procedure, from 3135 +/- 692 to 1025 +/- 551 ml/min (p =0.0001). The mean cardiac output rate decreased from 8 +/- 3.1 to 5.6 +/- 1.7 l/min (p = 0.001) with resolution of symptoms. During the follow-up period thrombosis or stenosis developed in seven patients, three of whom underwent surgical revision. Thirteen of the seventeen accesses (77%) subjected to the inflow reduction procedure remained patent. Access loss was due to failed fistuloplasty or thrombosis. To our knowledge, this is the first report demonstrating that inflow reduction obtained by distalization of the anastomosis of the access fistula is feasible and safe for managing high-inflow, high-cardiac-output fistulas. Longer and larger studies of the inflow reduction procedure and its benefits are needed.

Liver transplantation for hepatic arteriovenous malformation with high-output cardiac failure in hereditary hemorrhagic telangiectasia: hemodynamic study.

We describe a case of orthotopic liver transplantation used as a therapeutic method to correct high output cardiac failure related to a liver arteriovenous fistula due to hereditary hemorrhagic telangiectasia. Detailed hemodynamic changes as they occurred during liver transplantation are described.

[High output heart failure due to coronary fistula]. / Insuficiência cardíaca de alto débito devida a fístula coronária.

A 45 year-old woman complaining of heart failure symptoms (New York Heart Association--class III) and a non typical thoracic pain was submitted to a transthoracic echocardiogram which showed a very dilated coronary artery and a fistula to the right atrium. The angiograms confirmed the same findings. She underwent open heart surgery which confirmed the diagnosis. Fistula ligation was then undertaken. She remains symptom-free three years after the operation.

Devascularization and staged resection of giant sacrococcygeal teratoma in the premature infant.

Sacrococcygeal teratoma identified in utero is associated with 50% fetal demise, which is caused by hyperdynamic cardiac failure, hemorrhage, and polyhydramnios-induced preterm labor. A premature infant (26 weeks' gestation) with prenatally diagnosed sacrococcygeal teratoma was managed successfully with initial devascularization to control the hyperdynamic state, followed by staged resection.