Thread by @ArgaizR

A tale of two hearts: Physiological observations on AV shunts and congestion 🧵

These are 2 patients on IHD I saw in the outpatient clinic

🔷 Both with severe venous congestion (#VExUS = 3)
🔷 Both with tortuous brachiocephalic AV fístula

1/11

What I found remarkable was the diametrically opposed effects of manual AVF compression on JVP! 🤯

🔴 Patient A: AVF Compression improves venous congestion
🔵 Patient B: AVF Compression worsens venous congestion

2/11

🔴 Patient A: SLE + Lupus Nefritis ➡️ ESRD in HD

#echofirst: Plethoric IVC, good LVEF, paradoxical septal motion, ventricular interdependence, severe RV/RA dilation, torrential TR

3/11

🔴 Some Doppler for the nerds 🤓

LVOT VTI = 21.9
Cardiac Index = 4.38
TRVmax = Triangular shape (can't calculate RVSP with torrential TR)

This looks like severe PAH. The hx of SLE suggests group 1 PH

There is also high CI (>4) suggesting High Output Heart Failure (HOHF)!

4/11

🔵 Patient B: T2DM ➡️ ESRD in HD

#echofirst: Plethoric IVC, good LVEF, preserved LV/RV ratio, increased left filling pressures and mild TR (not shown, pleural effusion.

5/11

🔵 Some Doppler for the nerds 🤓

LVOT VTI = 29
Cardiac Index = 3.19 (normal)
TRVmax = 3.2

This looks like garden variety Heart Failure with Preserved Ejection Fraction (HFpEF)

6/11

To understand the physiology it helps to remember that the creation of an AV Fístula causes significant hemodynamic changes:

🔷 Lower SVR
🔷 Lower Afterload
🔷 Increased venous return and Preload
🔷 Increased Cardiac Output

academic.oup.com/eurheartj/arti…

7/11

Here is what I believe is happening!

🔑 AVF compression = ⬆️ Afterload and ⬇️ Preload

A🔴: PAH + torrential TR is more susceptible to ⬆️ Preload (Improves with AVF compression)

B🔵: HFpEP (Group 2 PH) is more susceptible to ⬆️ Afterload (Worsens with AVF compression)

8/11

A bit is more to this story:

Let's take a look at the AVFs!

A🔴: Flow = 1607 ml/min
B🔵: Flow = 1020 ml/min

Also, manual compression of the AVF improves #VExUS in A🔴 but does nothing for B🔵!

9/11

A🔴: High flow fistula (>1500 ml/min) + improving with compression suggests AV fistula is strongly contributing to RHF and HOHF

B🔵: Pt was actually 6 kg above "dry weight"

We decided to remove the AVF for A🔴 and intensify UF for B🔵

This achieved decongestion on both!

10/11

Patient A🔴 had PAH that was severely exacerbated by AVF induced HOHF!

Patient B🔵 had HFpEF, congestion was caused by volume overload!

#VExUS takes hemodynamic evaluation to another level!

We reported the findings on Patient A🔴 in this letter: academic.oup.com/ckj/advance-ar…

END/

BONUS:

Here is #echofirst from Pt A🔴 before and 24 hrs after fistula ligation:

There was immediate reversal of septal flattening!

1/2

Also there was reversal of Torrential TR, only moderate TR remained.

Formal echocardiogram after 3 weeks showed complete reversal of pulmonary hypertension and only mild TR

END OF BONUS