High-Output Heart Failure Associated With Arteriovenous Fistula

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: High-output heart failure (n=1). Intervention: Arteriovenous fistula flow-reduction surgery vs. Baseline (pre-surgery). Primary outcome: Cardiac output and AVF access flow.

Q: What does this research mean for the field?

Echocardiography combined with transient arteriovenous fistula (AVF) flow reduction during hemodynamic testing can reverse the high-output state and confirm the diagnosis of AVF-related high-output heart failure. Novelty: ClaimNovelty.METHODOLOGICAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

jihee Son; Sang Min Park; Ki Hong Choi; Jeong Hoon Yang; Eun Kyoung Kim; Sung-A Chang; Sung-Ji Park; Sang-Chol Lee; Seung Woo Park

doi:10.1016/j.jaccas.2026.107193

March 1, 2026JACC Case ReportsOpen Access

High-Output Heart Failure Associated With Arteriovenous Fistula

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Key result

AVF flow-reduction surgery cuts access flow ~62%, reversing high-output heart failure symptoms.

n=1

Figures

Graphical abstract published by JACC Case Reports — Graphical abstract · Published by JACC Case Reports · CC BY-NC-ND

Why the study?

AVF-related high-output heart failure is clinically significant but remains under-recognized in hemodialysis patients.

Does AVF flow-reduction surgery improve hemodynamics and symptoms in hemodialysis patients with AVF-related high-output heart failure?

Key Points

To evaluate and manage high-output heart failure caused by excessive shunt flow through an arteriovenous fistula in a hemodialysis patient.
Evaluated a 73-year-old woman receiving maintenance hemodialysis who presented with worsening exertional dyspnea 1 year after upper-arm arteriovenous fistula creation.
Conducted simultaneous right heart catheterization and transthoracic echocardiography before and during manual fistula compression, followed by surgical flow-modulation procedures.
Manual compression of the arteriovenous fistula reduced invasive cardiac output from 7.0 to 4.2 L/min (cardiac index from 5.5 to 3.3 L/min/m2) and increased systemic vascular resistance from 944 to 2,844 dyne⋅sec/cm5.
Transthoracic echocardiography during compression showed concordant reductions in cardiac output from 6.3 to 3.3 L/min (cardiac index from 5.0 to 2.6 L/min/m2).
Two surgical flow-reduction procedures decreased arteriovenous fistula access flow to 1,800 mL/min, resulting in reduced left ventricular chamber size and symptomatic improvement.

Study Design

Type

Case Report (n=1)

Structured PICO

Does AVF flow-reduction surgery improve hemodynamics and symptoms in hemodialysis patients with AVF-related high-output heart failure?

P

Population

One 73-year-old female hemodialysis patient with an upper-arm arteriovenous fistula who developed high-output heart failure and was followed for 8 months after surgical flow reduction.

I

Intervention

Arteriovenous fistula (AVF) flow-reduction surgery (banding) performed twice to modulate excessive shunt flow while preserving hemodialysis access.

O

Outcome

Reduction in AVF flow, improvement in hemodynamic parameters (cardiac output, systemic vascular resistance) and echocardiographic indices (LV chamber size, pericardial effusion), and resolution of heart failure symptoms.surrogate

In hemodialysis patients with unexplained heart failure, AVF-related high-output heart failure should be suspected, and transient manual AVF compression during echocardiography or right heart catheterization is a reliable and safe diagnostic tool.

Limitations

Single case report limits generalizability
Lack of prospective data to define risk thresholds for AVF flow and to determine survival benefit
Single patient case report
Current recommendations are largely based on case-based experiences rather than prospective trials

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Implication

Suggests AVF flow reduction for select high-output HF cases in hemodialysis; leaves open prospective validation of benefit.

Abstract

BACKGROUND: Arteriovenous fistulas (AVFs) are the preferred vascular access for hemodialysis, but they can cause high-output heart failure (HOHF) by imposing significant hemodynamic stress. Despite its clinical significance, AVF-related HOHF remains under-recognized in hemodialysis patients. CASE SUMMARY: during manual AVF compression. Two AVF flow-reduction procedures resulted in a reduction in left ventricular size and symptomatic improvement. DISCUSSION: This case highlights the need to consider HOHF in hemodialysis patients presenting with unexplained heart failure. Hemodynamic assessment-echocardiography or cardiac catheterization with AVF compression-can confirm the diagnosis and guide management. TAKE-HOME MESSAGE: In suspected AVF-related HOHF, echocardiography with transient AVF flow reduction during hemodynamic testing can reverse the high-output state and support the diagnosis.

Discussion

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Cite This Study

Son et al. (2026) conducted a case report in High-output heart failure (n=1). Arteriovenous fistula flow-reduction surgery vs. Baseline (pre-surgery) was evaluated on Cardiac output and AVF access flow. Arteriovenous fistula flow-reduction surgery successfully reduced AVF access flow from 4.79 L/min to 1.80 L/min, reversing high-output heart failure symptoms and promoting reverse remodeling.

synapsesocial.com/papers/69a7cd2ad48f933b5eed9397 https://doi.org/10.1016/j.jaccas.2026.107193

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High-Output Heart Failure Associated With Arteriovenous Fistula

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

High-Output Heart Failure Associated With Arteriovenous Fistula

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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