The Arteriovenous Fistula: An Often Overlooked Precipitant of HighOutput Heart Failure

Heart failure usually occurs in the setting of a low cardiac output, however in rare cases it may be associated with a high cardiac output. We present a rare and intriguing case of a patient with end-stage renal disease (ESRD) on hemodialysis that developed high output heart failure from his arteriovenous fistula (AVF). A 36 year old African American male with ESRD secondary to hypertension, on hemodialysis for six years, presented to emergency room with a history of chest pain and shortness of breath. He was diagnosed with congestive heart failure secondary to coronary artery disease. His transthoracic echo showed an ejection fraction of 65% and both the stress test and cardiac enzymes were negative for ischemia. Further workup revealed a cardiac output of 10.6 L/min and access flow of 2.37 L/min. We made a diagnosis of high output heart failure secondary to the AVF. He was taken to surgery for a minimally invasive limited ligation endoluminal-assisted revision (MILLER) procedure after which his symptoms resolved. High output heart failure, though a rare complication of AVF placement is an important differential in hemodialysis patients who present with symptoms of congestive heart failure. An accurate diagnosis will prevent morbidity and unnecessary hospital admissions.