ALL ABOUT THE FLOW - INSIGHTS INTO HIGH OUTPUT HEART FAILURE

Document Type

Conference Proceeding

Publication Date

4-1-2024

Publication Title

J Am Coll Cardiol

Abstract

Background High output heart failure (HF) is an uncommon etiology for HF, but an essential one to investigate given its high morbidity. Case A 74-year-old man with ESRD status post renal transplant, allograft nephropathy, HF presented with leg swelling, dyspnea, and respiratory failure. Patient has had multiple similar presentations previously. Physical exam was notable for respiratory distress, soft systolic murmur in the left upper sternal border, pitting lower extremity edema, and warm extremities. Blood work showed known renal dysfunction, minimal BNP and troponin elevations. ECG showed sinus rhythm, and CXR pulmonary congestion. Echocardiogram showed hyperdynamic LV ejection fraction, normal LV cavity size, wall thickness, indeterminate diastology, pulmonary artery pressure (PAP) 63 mmHg, and normal right ventricle (RV) size and function. Transaortic maximum velocity was 3.74 m/s, but valve area suggested mild stenosis. Cardiac output was 11.97 L/min, cardiac index 4.69 L/min/m2. Invasive hemodynamics showed mildly elevated right atrial pressure at 7 mmHg, mean PAP 22 mmHg, capillary wedge pressure 12. Cardiac output and index were 12.49 L/min, and 4.77 L/min/m2, systemic vascular resistance (SVR) 627 dynes/sec/cm2. Decision-making Given elevated cardiac output, patient's HF was thought to be secondary to a high flow state. He had an arteriovenous fistula (AVF) from prior dialysis. Interrogation of the AVF shows elevated flow at 1335 mL/sec. Patient underwent fistula revision with reduction in cephalic vein lumen size. Repeat echocardiogram showed normalized cardiac output and index, measuring 5.4 L/min and 2.24 L/min/m2. Patient has dramatic improvement in symptomatically. HF has numerous etiologies, and high disease burden. High output HF is relatively uncommon and is defined by increased cardiac output (greater than 8 L/min) and reduced SVR. It is secondary to other pathologies, such as obesity, shunts, liver, and lung disease. Persistence of AVF is an uncommon cause of high flow state but needs to be factored in. Conclusion AVF in rare instances contribute to high output heart failure and systemic workup could lead to correct diagnosis and management.

Volume

83

Issue

13

First Page

4191

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