IT'S NOT THE HEART

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: HOHF is suspected when patients present with clinical symptoms of CHF but have an elevated CI typically above 4L/min/m2 [1]. These can exhibit signs and PH as a result blood flows through the pulmonary vasculature. CASE PRESENTATION: A 56 year-old male kidney transplant recipient (KTR) presented shortness breath, lower extremity edema 3-months after cadaveric renal transplantation. He had history chronic mild systolic cardiac dysfunction (EF 50%), hypertension (WSPH group II), diabetes mellitus type 2 prior to Physical exam was significant for +3 pitting bilateral extremities, crackles at lung bases right brachiocephalic AVF palpable thrill. Serum creatinine 3.5mg/dL (baseline 2.0mg/dL) Chest X ray showed edema. Diuresis improved worsened function. Renal biopsy negative rejection. Echocardiography (TTE) revealed ventricular pressure (RVSP) severely dilated atrium (RA) ventricle (RV). Right heart catheterization demonstrated left sided filling pressures moderate (PH) output/index (CO/CI). An occlusion in cath lab resulted reduction CO 7.75 L/min 3.10 L/min/m2 by thermodilution. Findings were consistent secondary high output failure (HOHF), likely related AV fistula. underwent revision improvement DISCUSSION: common ESRD undergoing HD via [2] could be easily addressable cause ESRD. difficult diagnose based on echocardiography alone. RHC shows (> 8L/min, CI>4L/min/m2), AVF/G flow > 1.5L/min, cardiopulmonary recirculation ratio (CPR) 0.3 [3]. Furthermore, transplantation appears adverse impact allograft function recipients [4]. In retrospective analysis KTRs single institution, 29/113 (26%) required closure their due symptomatic CHF. The mean rate significantly requiring compared those managed conservatively (2197 ml/min vs. 851 ml/min) [5]. High rates increased arterial shunted from circulation preload stroke volume hypertrophy leading subsequent [6]. CONCLUSIONS: our patient, aneurysmal acute cardio-renal syndrome 1(CRS - 1) transplanted kidney. both following confirmed diagnosis cardiorenal injury AVF. REFERENCE #1: Reddy YN, Obokata M, Dean PG, Melenovsky V, Nath KA, Borlaug BA. Long-term cardiovascular changes creation arteriovenous fistula end stage disease. Eur Heart J. 2017 Mar 6. #2: Schoenberg NC, Argula RG, Klings ES, Wilson KC, Farber HW. Prevalence Mortality Hypertension ESRD: Systematic Review Meta-analysis. Lung. 2020 Jun;198(3):535-45. #3: Wijnen E, Keuter XH, Planken NR, van der Sande FM, Tordoir JH, Leunissen KM, et al. relation between vascular access different types systemic hemodynamics hemodialysis patients. Artif Organs. 2005 Dec;29(12):960-4. DISCLOSURES: Advisory Committee Member relationship Janssen pharmaceutical Please note: 4/2020 4/2021 Added 04/27/2021 Rahul Argula, source=Web Response, value=Consulting fee United Therapeutics 2019-2021 Breathe Technologies 2019 feeeducational grant Reata pharmaceuticals 2018-2019 value=Grant/Research Consultant Accordant health / CVS 2021 no disclosure file mona haj; No relevant relationships Elena Vlachos, Response