INTRODUCTION: Valvular heart disease is common in patients with end stage renal disease undergoing hemodialysis. Patients with preexisting right heart failure and severe tricuspid regurgitation (TR) might experience worsening of the heart failure symptoms and hypotension after arteriovenous graft (AVG) placement.
CASE PRESENTATION: A 77-year-old Caucasian female with known severe TR was admitted electively for AVG placement for hemodialysis due to history of worsening chronic renal failure. The patient underwent 6 x 40 mm Gore-Tex nonheparinized vascular graft in the right groin. Post procedure, patient was noted to be hypotensive with systolic blood pressure of 80 mm Hg and heart rate of 59 beats / min. Physical examination was remarkable for jugular venous distension, hepatojugular reflux, irregular heart rhythm, holosystolic murmur along the left sternal border and bilateral lower extremity edema. Chest examination was unremarkable. Laboratory data showed normal electrolytes. Her Blood Urea Nitrogen and serum creatinine were 73 mg/dl and 2.1 mg/dl respectively. Electrocardiogram done post procedure showed atrial fibrillation with controlled ventricular response (heart rate 49 beats / min), right axis deviation and diffuse ST segment depressions suggestive of ischemia. An emergent limited transthoracic echocardiogram (TTE) was done which showed left ventricular ejection fraction of 50 -55 % with no regional wall motion abnormalities, severe TR, severely dilated tricuspid annulus (5.5 cm) and right ventricular enlargement. There was no evidence of interatrial shunting of blood. Patient was started on vasopressors intravenously due to hypotension. Evaluations of cardiac biomarkers post procedure showed rise and fall of troponin I level and peak troponin I level of 7.71ng/ ml consistent with post procedure myocardial infarction (MI). MI was thought to be type 2 MI related to systemic hypotension. Patient continued to have stable hemodynamics on vasopressors however she could not be weaned off them despite 48 hours of hemodynamic support. Thus, ligation of AVG was done for improvement in hemodynamics, which resulted in improvement in blood pressure and weaning off vasopressors. Patient underwent right heart catheterization due to uncertain etiology of her tricuspid regurgitation which showed elevated mean right atrial pressure of 17 mm Hg. Right ventricular systolic pressure was 34 mm Hg and right ventricular end diastolic pressure was 14 mm Hg. Pulmonary artery pressure was 36/14 mm Hg and mean pulmonary artery pressure was 22 mm Hg. Cardiac output calculated by Fick equation was 4.8 liters/ minute and pulmonary vascular resistance was 116 dyne.s/cm5 (< 2 Wood units). Pulmonary capillary wedge pressure was 17 mm Hg. There was no evidence of pulmonary hypertension to explain the severity of tricuspid regurgitation. Thus we made the diagnosis of idiopathic tricuspid annular dilation.
DISCUSSION: Moderate and severe TR is present in 13% and 5% of patients with end stage renal disease undergoing hemodialysis (1). Idiopathic TR was reported in 9.5 % of patients in a series of 242 consecutive patients with severe tricuspid regurgitation by Mutlak et al (2). AVG placement in such patients results in sudden shunting of large volume of blood to the right side with progressive right ventricular dilatation, increase in intrapericardial pressure and movement of interventricular septum to the left side with resultant decrease in stroke volume due to decrease in size of the left ventricular outflow tract and cardiac output.
CONCLUSIONS: Patients with preexisting right heart failure and severe TR might experience worsening of the heart failure and hypotension after AVG placement. Patients should be screened for symptoms and signs of right heart failure and severe TR prior to AVG placement.
Reference #1 Stinebaugh J et al. South Med J 1995; 88 (1): 65.
Reference #2 Mutlak D. J Am Soc Echocardiograph 2007; 20 (4): 405-8.
DISCLOSURE: The following authors have nothing to disclose: Anand Deshmukh, Susan Schima, Michael White, Amy Arouni, Mark Holmberg
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