Development of a Large Pericardial Effusion in a Patient With High-Output Heart Failure and Cardiogenic Shock From an Arteriovenous Fistula

A 58-year-old male with a history of end-stage renal disease on hemodialysis presented with a one-week history of shortness of breath, weakness, and hypotension and was transferred to our institution with concern for cardiogenic shock complicated by severe pulmonary hypertension (HTN) and a large pericardial effusion. Diagnostic workup was concerning for high-output heart failure secondary to his arteriovenous fistula as the underlying etiology, although this was complicated by other potential etiologies, including severe pulmonary HTN and subsequent decompensation from GI hemorrhage. Notably, the pericardial effusion was in a posterior location not amenable to pericardiocentesis. Surgical ligation of the fistula was performed alongside aggressive fluid removal with continuous renal replacement therapy (CRRT), resulting in gradual stabilization of his condition and ultimately complete resolution of his pericardial effusion without the need for percutaneous drainage. This case demonstrates high-output heart failure and cardiogenic shock, an already rare, potentially fatal complication of hemodialysis fistulas, with an associated large pericardial effusion that was successfully managed with surgical ligation of the fistula and CRRT.