title: Cardiac remodeling after reduction of high-flow arteriovenous fistulas in end-stage renal disease.
abstract: In patients with end-stage renal disease, excessive blood flow through an arteriovenous fistula (AVF) may lead to volume overload-induced cardiac remodeling and heart failure. It is unclear which patients with hyperfunctional AVF may benefit from AVF reduction or ligation. The indication for the procedure is often based on AVF flow. Because cardiac remodeling is driven by increased venous return, which is equivalent to cardiac output, we hypothesized that an elevated cardiac index (CI) might better identify subjects with reverse remodeling after AVF reduction. Thirty patients (age 52±12 years, 73% male) with AVF flow ⩾1.5 l min(-1) underwent comprehensive echocardiographic evaluations before and after AVF reduction. At baseline, 16 patients had a normal CI (2.5-3.8 l min(-1) m(-2)) and 14 had a high CI (4.0-6.0 l min(-1) m(-2)). A left ventricular end-diastolic diameter decrease after operation was predicted by elevated baseline CI (P<0.01), but not elevated AVF flow (P=0.07). There was a significant decrease in CI, left ventricular mass, left atrial and right ventricular diameter and pulmonary systolic pressure in the high CI group but not in the normal CI group. After AVF reduction, systemic vascular resistance decreased in the normal CI group, whereas it did not change in the high CI group. In conclusion, reduction of high-flow AVF leads to reverse cardiac remodeling but only in patients with elevated CI. The variability of the response of systemic vascular resistance to AVF flow may explain this observation. Increased CI but not increased AVF flow may better determine candidates for AVF reduction.
authors.affiliation: Center for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic.|Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic.|International Clinical Research Center, St Anne's University Hospital, Brno, Czech Republic.
authors.forename: Peter
authors.initials: P
authors.lastname: Wohlfahrt
authors.affiliation: Vascular and Transplant Surgery Department, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic.
authors.forename: Slavomir
authors.initials: S
authors.lastname: Rokosny
authors.affiliation: Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic.
authors.forename: Vojtech
authors.initials: V
authors.lastname: Melenovsky
authors.affiliation: Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, Rochester, MN, USA.
authors.forename: Barry A
authors.initials: BA
authors.lastname: Borlaug
authors.affiliation: Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic.
authors.forename: Vera
authors.initials: V
authors.lastname: Pecenkova
authors.affiliation: Department of Surgery, Faculty Hospital Kralovske Vinohrady, 3rd Medical Faculty, Charles University, Prague, Czech Republic.
authors.forename: Peter
authors.initials: P
authors.lastname: Balaz
mesh_terms: D000328:Adult; D000368:Aged; D001164:Arteriovenous Fistula / Q000000981:diagnostic imaging / Q000503:physiopathology*; D004452:Echocardiography; D005260:Female; D006321:Heart / Q000000981:diagnostic imaging / Q000503:physiopathology*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D020257:Ventricular Remodeling / Q000502:physiology*