American Heart Association Council on Clinical CardiologyLaennec Young Clinician Award Finalist PresentationNovember 15th, 2014

Natalia Berry, MDPiotr Sobieszczyk, MDJoshua Beckman, MD

The Thrill is Gone: An Interesting Cause of Congestive Heart Failure

• 85F with atrial fibrillation, recent onset congestive heart failure presents with dyspnea

• Sleeping more upright, could only walk room to room, and had a nonproductive cough

• She is admitted for congestive heart failure exacerbation

• Recent history notable for:

• Progressive fatigue and dyspnea for past year

• Treated with diuretic therapy for presumed congestive heart failure by outpatient cardiologist for past 3 months

• Five hospitalizations for hematochezia over previous 6 months

• Extensive workup (3 colonoscopies, 1 upper endoscopy, 1 capsule study) notable only for severe diverticulosis

• Warfarin discontinued after hospitalization #3, aspirin discontinued after hospitalization #4

• Cause of hematochezia and worsening exertional dyspnea not established 2

History of Present Illness

• Past Medical History: HTN, glaucoma, OA

• Allergies: none

• Medications: Bumetanide1mg daily, metoprololsuccinate 50mg daily, omeprazole 40mg daily, Fe supplements

Medical History

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• Social History: Widowed, lives in apartment attached to her daughter’s home; never smoker, rare EtOH, no illicits

• Family History: Colon Ca in mother, no CAD, no SCD

• VS: T 98.7oF HR 74bpm irregular, BP 110/56mmHg, RR 16/min, O2 saturation 85% on RA (96% on 3L)

• General: Elderly, Caucasian woman. Cachectic, no acute distress.

• HEENT: PERRL, EOMI, (-) scleral icterus, OP clear

• Neck: JVP 18 cm H2O with prominent v waves, 2+ carotid upstrokes, (-) bruits

• Pulm: Bibasilar rales, otherwise clear to auscultation, (-) wheezes, rhonchi

Physical Examination

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• CV: Irregularly irregular rhythm, PMI diffuse and laterally displaced, normal S1 & S2, III/VI HSM at LLSB, murmur increased with inspiration, murmur decreased with expiration and Valsalva, (+) RV heave

• Abd: soft, nontender, (+) fluid shift, area of 2cm x 2cm bruit in R flank area w/ thrill, bruit continuous throughout cardiac cycle

• Extr: Cool below knees, (-) edema, 2+ brachial, radial, DP/PT pulses

• Neuro: CN II-XII intact, 5/5 strength upper and lower extremities

• Skin: (-) rashes, lesions, nevi, telangiectasias, hemangiomas

Physical Examination

5

137

3.4

99 29

26 1.33106

33.43385.3

1.4

17 38.3

NT-proBNP 4497 pg/mL

Troponin T 0.02 ng/mL

CK 92 ng/mL

CK-MB 4.5 ng/mL

Laboratory Studies

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Chest X Ray

7

Electrocardiogram

8

Transthoracic Echocardiogram

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Parasternal short axis view Apical 4 chamber view

Transthoracic Echocardiogram

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IVC inflow

• Findings of biventricular failure on examination, predominant RV dysfunction, biatrial enlargement and pulmonary hypertension on echocardiogram, atrial fibrillation

• Valvular heart disease (the newly recognized murmur)

• Primary pulmonary HTN

• Restrictive cardiomyopathy

• High output cardiac failure given abdominal bruit and thrill

• Abdominal CTA scan ordered to define the vascular abnormality

Case Synthesis

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Abdominal CT Scan

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IVC

Renal

vein

Aneurysm

Abdominal CT Scan

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Abdominal CT Scan

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Abdominal CT Scan

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• Both AF and CHF likely caused by chronic high output state

• Hematochezia likely due to chronically elevated visceral venous pressure

• Recommended right heart catheterization for hemodynamic assessment and fistula characterization

AVFChronic

high output

AF CHF

GI Bleeds

Diagnosis: Arteriovenous Fistula as Root Cause

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• RA 23, RV 61/27, PA 58/26, PCWP 23

• CO output 8.54L/min (Fick estimate)

• Arteriography: single R renal artery supplying 4.5cm aneurysm that drained into R renal vein

• With temporary fistula occlusion:

• CO decreased to 4.66L/min

• Fixed pulmonary HTN

• Fistula amenable to percutaneous closure

Cardiac Catheterization and Arteriography

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1. Surgical repair

2. Endovascular repair

3. Medical management

• Benefits – potential improvement of CHF, GIB, abrogate risk of rupture

• Risks – age and frailty at presentation, risk inherent to procedure, unclear reversibility given calcification and chronicity

Given caliber of fistula and hemodynamic consequences,

endovascular repair recommended to patient

Treatment Options

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Case Management

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• Patient and daughter elected to proceed with percutaneous closure

• Procedure performed 6 weeks after discharge

• 22 coils, 2 vascular plugs

• Patient has been seen for three outpatient visits since fistula closure

• Patient feels she has gained a ‘new life’

• Improved energy, appetite, dyspnea has nearly resolved

• 3 months post procedure: off diuretics

• 6 months post procedure: anticoagulants started, no recurrent bleeding x 2 months

Outpatient Follow Up

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• 85F with atrial fibrillation, congestive heart failure, recurrent hematochezia, and worsening dyspnea

• Physical exam was key to diagnosis

• Chronic arteriovenous fistula causing high output state root cause of AF, CHF, GI bleeding

• Percutaneous closure of fistula resulted in marked improvement in patient’s course

Summary

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• 442 consecutive patients admitted from the emergency department to an academic medicine department

• Primary outcome: main diagnosis compared with final diagnosis

History and Physical as Most Powerful Diagnostic Modality

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Modality CorrectSenior Resident

Diagnoses (%)Hospitalist

History alone 19.8 19.3

Physical exam alone 0.8 0.5

Basic tests alone 1.1 1.3

History and Exam 39.5 38.6

History, Exam, and basic tests

16.9 18.5

Role of imaging on admission

6.5 6.1

Arch Intern Med. 2011;171(15):1393-1400

• Joshua Beckman, MD

• Piotr Sobieszczyk, MD

• Patrick O’Gara, MD

• Donna Polk, MD

• Marie Gerhard-Herman, MD

• Marc Creager, MD

• Pradeep Natarajan, MD

• William Hucker, MD

• Sunil Kapur, MD

• MGH/BWH Cardiology Fellows

• American Heart Association / Laennec Committee

Acknowledgements

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• Hirai S, Hamanaka Y, Mitsui N, Kumagai H, Nakamae N. High-output heart failure caused by a huge renal arteriovenous fistula after nephrectomy: report of a case. Surg Today 2001;31:468-70.

• Durakoglugil ME, Kaya MG, Bulent B, Cencel A. High-output heart failure 8 months after an acquired arteriovenous fistula. JpnHeart J 2003;44:805-809.

• Nagahara A, Nishimura K, Okuyama A. A giant idiopathic renal arteriovenous fistula associated with high-output heart failure. International journal of urology: official journal of the Japanese Urological Association 2009;16:648-9.

• Oishi AJ, Nagorney DM, Cherry KJ. Portal hypertension, variceal bleeding, and high output cardiac failure secondary to an intrahepatic arterioportal fistula. HPB surgery: a world journal of hepatic, pancreatic and biliary surgery 1993;7:53-9; discussion 1-2.

• Lin CP, Cheng JS, Lai KH, Lo GH, Pan HB. Recurrent gastrointestinal bleeding and high output cardiac failure caused by hereditary hemorrhagic telangiectasia. Zhonghua yi xue za zhi = Chinese medical journal; Free China ed 2000;63:339-43.

• Bates MC, Almehmi A. High-output congestive heart failure successfully treated with transcatheter coil embolization of a large renal arteriovenous fistula. Catheter Cardiovasc Interv 2004;63:373-6.

• J. Porter et al,. A Case of Femoral Arteriorvenous Fistula Causing High-Output Cardiac Failure. Case Rep Vasc Med; 2014;510429.

• Paschalis-Purtak et al. Arteriovenous fistula of the kidney: a case report of 47-year-old female patient treated by emoblisation. J of Human Hypertension 2003;17:293-296.

• Lekuona I, Laraudogoitia E, Salcedo A, Sadaba M. Congestive heart failure in a hypertensive patient (don't forget

the stethoscope). Lancet 2001; 357: 358.

References

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• Natalia Berry: none

• Joshua Beckman: Research Grant – BMS; Ownership Interest – Janacare, EMX; Consultant/Advisory Board – Novartis, Merck, BMS, Astra Zeneca

• Piotr Sobieszczyk: none

Disclosures

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