Abstract 16251: Back to Basics: Diagnosing a Hidden Cause of High-Output Cardiac Failure
An 85-year-old female with a history of AF and recent onset CHF presented with progressive dyspnea and langour. Her history was notable for five episodes of recurrent hematochezia over the previous 6 months. Extensive evaluation was unrevealing necessitating cessation of her anticoagulation. Initial current inpatient physical examination was notable for elevated JVP and a II/VI holosystolic murmur. TTE revealed normal LVEF, RV enlargement with moderately decreased function, pulmonary hypertension, severe tricuspid TR and a dilated IVC. Abdominal ultrasound showed a calcified structure with arterial flow adjacent to the right kidney and possible renal artery aneurysm. Vascular Medicine was consulted. On our physical exam, we noted a loud right sided flank bruit that persisted throughout the cardiac cycle, and abdominal CT revealed a large right renal AV fistula with 4.5 cm renal artery aneurysm. Right heart catheterization to characterize the hemodynamic effect of the fistula revealed elevated filling pressures (RA = 23mmHg, PCW = 22mmHg) and pulmonary hypertension (58/26mmHg); cardiac output decreased from 8.54L/min to 4.66L/min with temporary occlusion of the fistula. We postulated that this chronic, hemodynamically significant fistula was the cause of her longstanding AF and right-sided heart failure with recent onset congestion. Moreover, elevated visceral venous pressures were the likely cause of her recurrent GI bleeding. After an extensive discussion about the potential benefits and risks of percutaneous fistula closure, the patient and daughter elected to proceed. Since successful fistula closure, the patient reports significantly improved energy levels and nearly complete resolution of her exertional dyspnea. She has tolerated the reintroduction to antiplatelet therapy without further GI bleeding.
This case describes an unusual cause of high-output cardiac failure. Given the likely chronicity of the fistula, fastidious physical examination may have identified the diagnosis much earlier. However, despite her advanced age and likely decades since the onset of the fistula, percutaneous closure of the fistula and correction of the cause of failure conferred profound improvement in functional status and quality of life.
Author Disclosures: N.C. Berry: None. P. Sobieszczyk: None. J. Beckman: Research Grant; Modest; BMS. Ownership Interest; Modest; Janacare, EMX. Consultant/Advisory Board; Modest; Novartis, Merck, BMS, Astra Zeneca.
- © 2014 by American Heart Association, Inc.