Cardiac Failure, Pulmonary Hypertension Secondary to Renal AVM

Abstract and Introduction

Abstract

Background: Heart failure is usually associated with a low-cardiac-output state; however, a minority of these patients are characterized by a high-output cardiac state, described as a cardiac index of > 4 L/minute/m². Usually such circulation is associated with low systemic vascular resistance or arteriovenous malformation (AVM), resulting in depressurized circulation and a high-output cardiac state. Treating physicians should be cognizant of such pathology when investigating patients with heart failure. As an example, renal arteriovenous malformations are a rare vascular phenomena that are typically the result of iatrogenic, traumatic or congenital etiology. Generally, non-salient, most are detected as an incidental finding.

Case Presentation: A 75-year-old Afro-Caribbean man with multiple comorbidities presented to the emergency department with a 6-month history of heart failure symptoms. Cardiac catheterization demonstrated a giant right renal AVM leading to a significant left-to-right, post-tricuspid shunt that was treated with transcatheter coiling.

Conclusions: We present this case to emphasize the significance of a detailed workup in a patient with heart failure symptoms.

Introduction (Background)

Heart failure is usually associated with a low-cardiac-output state; however, a minority of these patients are characterized by a high-output cardiac state, described as a cardiac index of > 4 L/minute/m².^[1] Usually such circulation is associated with low systemic vascular resistance or arteriovenous malformation (AVM), resulting in depressurized circulation and a high-output cardiac state.^[2] Treating physicians should be cognizant of such pathology when investigating patients with heart failure. As an example, renal AVMs are rare vascular phenomena that are typically the result of iatrogenic or traumatic events, although they can be congenital in etiology.^[3] Generally non-salient and asymptomatic, most are detected as an incidental finding.^[4,5] The exception is congenital AVMs, which may create a left-to-right shunt resulting in venous congestion, pulmonary hypertension, and high-output cardiac state. A literature review (with key words "renal arteriovenous malformation" and "pulmonary hypertension") was performed using the PubMed, MEDLINE, Embase, Cochrane, and Scopus databases. Six case reports were found.^[3,6–10] The paucity of clinical data underscores the rarity of this clinical scenario and the importance of highlighting a reversible cause of flow-related pulmonary hypertension and high-output cardiac states.